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Education
Public health nursing education in Turkey: a national survey H. Kadioglu1
RN, PhD, S.
Albayrak2
RN, PhD
& M.N. Esin3
RN, PhD
1 Assistant Professor, Department of Community Health Nursing, Health Science Faculty, Marmara University, 2 Assistant Professor, Division of Nursing, Health Science Faculty, Kırıkkale University, 3 Associate Professor, Department of Community Health Nursing, Florence Nightingale Nursing Faculty, Istanbul University, Istanbul, Turkey
KADIOGLU H., ALBAYRAK S. & ESIN M.N. (2013) Public health nursing education in Turkey: a national survey. International Nursing Review 60, 536–542 Aim: To investigate public health nursing content in undergraduate and postgraduate programmes in Turkey. Methods: This study included all of the nursing schools in Turkey that provide university level education. The data were collected through a self-administered questionnaire designed to identify the existing status of undergraduate and postgraduate public health nursing education between February 2011 and June 2011. The questionnaire was completed only by the head of the department of public health nursing in each school. Data were analysed with descriptive statistics using SPSS for Windows 17.0 software. Results: The study achieved a response rate of 72.5%. All participants reported offering a course in public health nursing in their undergraduate programmes. Fourteen (24.1%) participants reported offering Master of Science degrees in public health nursing. Seven (12.1%) participants reported offering doctorate degrees in public health nursing. In the responding schools, the public health nursing course was given in one semester (14 weeks) for an average of 5.54 ⫾ 1.43 h/week for theory and an average of 13.48 ⫾ 5.11 h/week for clinical practice. Of the participants, 43 (74%) reported problems related to public health nursing education. Conclusion: There are problems in Turkey with regard to public health nursing education. The nursing school curriculum must be revised on a national level if public health nursing is to be revived and strengthened. Keywords: Postgraduate Education, Public Health Nursing, Undergraduate Education
Introduction In the early 21st century, factors such as the rapid increase in the world population, scientific and technological developments, and the steady decrease in the resources needed for human existence have brought about issues that include migrations, unemployment, nutritional problems, endemic and
Correspondence address: Mrs Hasibe Kadioglu, Department of Community Health Nursing, Marmara University, Tibbiye cad. No: 40, Haydarpasa-Istanbul 34668, Turkey; Tel: 00902164181606/1134; Fax: 00902164183773; E-mail: [email protected].
Source of funding: None.
© 2013 International Council of Nurses
pandemic epidemics, mother and child health and public health issues. These are problems not only for any one country, but for all countries. Issues have become global. Primary health care and the public health nurses that provide this care play a key role in finding solutions to these problems. Public health nursing (PHN) is a specialized field within the nursing profession. It is a branch of nursing that is focused on the population since its practitioners often work with members of the general public who are not in hospitals or other healthcare institutions. Its practitioners also focus on the relationship between the health of the population and the environment, concentrating on physical, biological and socio-cultural factors that play a role in meeting public health needs (Stanhope & Lancaster 2003).
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It is unfortunate that the liberal and free-market policies that emerged out of the globalization that took place after World War II have pushed primary healthcare services into the background. In an atmosphere where liberal policies are dominant, international monopolies find no legal obstacle to prevent them from producing their products at the lowest cost and selling these at the highest profit margins. This is turning the entire world into a free market zone. The developments that we are witnessing today in healthcare services all around the world are a consequence of such policies. Health care is seen as a most profitable area of business, in particular, diseases are the elements that constitute the source of profit in healthcare services. Liberal policies have resulted in a focus on private health services where the ‘user pays’ for health services. In such an environment, multinational corporations that produce and distribute pharmaceuticals and products of medical technologies on a global scale have become so powerful that they are allowed to shape health economies and trends. Compounding these global policies, the World Bank and the International Monetary Fund try to energize the global economy by extending loans to underdeveloped and developing countries. They seek in return that these countries adopt reforms that lead to the privatization of their healthcare services (Altay 2007; Robinson 1999). Thus, the services provided by government and social state have started to be replaced by private sector services that accept the sovereignty of the free market. General nursing and PHN education in Turkey
Nursing schools began to open in Turkey after World War I and the first nursing school was established in 1920. In 1925, the first nursing high school of the Republican Period opened, and in 1955, the first 4-year college-level nursing programme in Europe started in Turkey under the name of Ege (Aegean) University College of Nursing. A master’s programme was instituted in 1968, followed by the establishment of a doctoral programme in 1972 (Yavuz 2004). PHN is an essential content in undergraduate nursing programmes in Turkey. Specialty programmes in PHN curriculums exist at the master’s and doctoral levels. A master’s programme in PHN was started in Turkey in 1982; the doctoral programme was launched in 1985. PHN in Turkey were identified for the first time in 1961 in the ‘Regulations on the Execution of Services in Regions where Health Services have been Socialized’, based on Law no. 224 (Official Gazette of Republic of Turkey 1961) and public health services continued under these regulations until 2004. Turkey began to feel the effects of globalization more closely after 1980. Every government coming into office after 1980 included healthcare reform in their programmes. These reforms
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were never implemented however until 2004. In that year, in return for the loans extended by the World Bank, Turkey began to implement a series of health reforms under the name of ‘Health Services Transformation’ (Official Gazette of Republic of Turkey 2004). These reforms were completed in 2012. The reforms have three main components. The first is the transition to the family physician system in primary healthcare services. The second is related to making the state hospitals autonomous and the third to the transition into a general health insurance plan. This new system, in which the system of family medicine has been incorporated into primary healthcare services, has affected the services and the education of public nurses. The system operates with private medical professionals working as family physicians accompanied by nurses who are considered health workers. In the family medicine system, the nurse is designated as a ‘family health attendant’ working with the family health doctor. A family health attendant may be a nurse, midwife, emergency medical technician or similar professional. Thus nurses, who had a fundamental role in basic healthcare services within the law passed in 1961, have been neglected and not made a significant part of the new family medicine model (Uysal 2005). Together with these changes, two other developments have occurred with respect to nursing in Turkey. The first is the Law on Nursing, passed in 2007 (Official Gazette of Republic of Turkey 2007), and the second is the Regulations on Nursing initiated in 2010 that sets forth the duties, powers and responsibilities of nurses (Official Gazette of Republic of Turkey 2010). In these regulations, the duties, powers and responsibilities of homecare nurses, mother and child health and family planning centre nurses, community mental health centre nurses, occupational health nurses, school health nurses and penitentiary nurses were defined under the general heading of PHN but the duties, powers and responsibilities of the public health nurse as a separate entity was not defined. In fact, the new health reform does not even include public health nurses. Under these circumstances, the new health reforms and new arrangements question what kind of education a public health nurse must have. PHN education in the 4-year undergraduate nursing programme in Turkey consists of a single-semester course. There are no postgraduate certification programmes available. It is important for the development of public health in Turkey to establish standards and competencies in PHN education. There is no data available at this time about which subjects are included in undergraduate and postgraduate programmes in Turkey or about the duration of PHN education in general. Before regulations can be initiated, the present status of public health education must first be determined. A review
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must be made of whether there are differences of curriculum between schools, what qualifications are held by educators, the length of current theoretical and practical PHN education programmes, curriculum content, the different scopes of practice and what problems the health reform has brought to nursing school programmes. This article reports the findings of a national survey of PHN in undergraduate and postgraduate nursing programmes. This was the first study of its kind conducted at a national level in Turkey to evaluate the PHN education provided at the undergraduate and postgraduate levels. In addition, this survey was intended to provide baseline data on the current status of PHN in the undergraduate–postgraduate nursing curriculum to provide some comparative basis for future studies. The aim of the study was to investigate Turkish PHN education. This was addressed by the study questions: 1 Which courses are included and what length of time is given to PHN courses in undergraduate and postgraduate education? 2 What are the qualifications of the educators who teach PHN classes in undergraduate and postgraduate education? 3 What are some of the problems faced by educators in the nursing school programmes?
Methods Design and sample
This quantitative descriptive study included all of the nursing schools in Turkey (n = 92) that provide university level education (OSYM 2011). Since 12 of the schools listed were newly established institutions, these were excluded from the study. Permission for the study was obtained from the relevant university presidents by the president of the university at which the first author of the present study works. The selfadministered questionnaires were completed only by the heads of the departments of PHN in each school. A total of 80 schools of nursing were therefore invited to participate with questionnaires distributed via e-mail. Email addresses for the heads of the departments of PHN were updated from the relevant university website. A brief letter outlining the goals of the questionnaire and details of the study was included with each email invitation. An email reminder and a paper copy of the questionnaire were also sent to prospective respondents in the month following the initial distribution of the surveys in an effort to maximize the response rate. The institutional review board of Semahat Arsel Nursing Education and Research Center, Koç University, Istanbul, Turkey, approved this study.
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Measures
The data were collected through self-administered questionnaire designed to identify the existing status of undergraduate and postgraduate PHN education between February 2011 and June 2011. The questionnaire was based on previous studies and literature (Carter et al. 2006; Education Committee of the Association of Community Health Nurse Educators 2010; Esin et al. 2008; Feenstra 2000; Kurlowicz et al. 2007; Levin et al. 2008) as well as on the researcher’s practical experience. The questionnaire comprised four parts with a total of 21 items. In the first section, there were four items that asked for quantitative information and details of the qualifications of the academic faculty and the school. In the second section, there were five items that evaluated the topics taught and the length of PHN in undergraduate education. In the third section, there were ten items that evaluated the names of the courses and the length of PHN in postgraduate education. The fourth section comprised two items that asked the heads of the PHN departments their opinion about problems and solutions in PHN education.
Data analysis
Data were analysed with descriptive statistics using SPSS for Windows 17.0 software (SPSS Inc., Chicago, IL, USA). Similar answers to the open-ended questions were grouped together and every group was given a numerical code. These codes were entered into the program as data.
Results Of the 80 schools surveyed, 22 did not respond; the number of respondents was 58, making the response rate 72.5% (n = 58). All schools reported offering a course in PHN in their undergraduate programmes. Fourteen (24.1%) schools reported offering Master of Science degrees in PHN. Seven (12.1%) schools reported offering PhDs in PHN (Table 1).
Academic qualifications of lecturers
There were 132 lecturers responsible for teaching PHN in the 58 schools. The average number of instructors per school was 2.2. Twenty-seven (46.6%) schools had only one instructor. It was found that the average number of students per instructor was 34.04. Of the faculty members, ten (8%) were professors, five (4%) were associate professors, 40 (32%) were assistant professors; 56 (42%) had master’s degree; 21 (16%) had only bachelor’s degrees. Ninety-two (70%) of the academics had a degree in the area of PHN. The others had degrees in other nursing
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Table 1 Characteristics of public health nursing undergraduate and postgraduate education in Turkey Programmes
n (%)
Course
n
Mean of TCD
Mean of TED
Mean of PED
Undergraduate Master of Science
58 (100) 14 (24.1)
Public health nursing All courses Concepts and theory Nursing research Biostatistics Health promotion Health education Home care Epidemiology All courses
58 – 14 9 8 8 5 5 4 –
266.44 424.93 164.73 38.50 34.00 47.00 39.20 56.00 45.50 585.20
77.60 244.7 71.40 38.50 34.00 24.50 22.40 22.40 31.50 341.60
188.84 180.23 93.33 – – 22.50 16.80 33.60 14.00 243.60
Doctorate
7 (12.1)
PED, practical education duration; TCD, total course duration; TED, theoretical education duration.
branches (women’s health, epidemiology, paediatrics, health education, etc.).
the findings related to the classes in these programmes would not provide significant results.
Undergraduate education
Problems in PHN education
In the responding schools, the PHN course was given in one semester (14 weeks) for an average of 5.54 ⫾ 1.43 h/week (range 2–9 h) for theory and an average of 13.48 ⫾ 5.11 h/week (range 4–32 h) for clinical practice. PHN topics in undergraduate nursing education with the highest theoretical education duration percentages were ‘Introduction to PHN’ (93.1%), ‘Health policies’ (93.1%), ‘Elderly health’ (93.1%), ‘Home visiting’ (91.4%) and ‘School health nursing’ (91.4%). The respondents worked at a variety of clinical placement sites to practice PHN. More than two-thirds (74%) of the clinical placement sites were family health centres and 51% of the programmes utilized school health offices for their clinical placements. Another 35% made use of rest homes, 33% made placements in public health centres and 32% in occupational health offices for practical education. Ambulatory, home care and other clinical placement sites were used by approximately one-fifth of the respondents. It must be noted here that many programmes reported making multiple types of clinical sites available for their PHN courses.
Of the participants, 43 (74%) reported problems related to PHN education. Participants said that the most important problems were the lack of quality clinical sites (74%), the lack of role models in clinical settings (43%) and an insufficient number of qualified lecturers (41%).
Graduate education
Because the number of schools offering postgraduate and doctoral programmes was very few, the researchers concluded that
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Discussion This study tried to identify and describe the current status of undergraduate and postgraduate programmes in PHN in Turkey. It was found that more than half of the academics in the field (58.4%) do not have a doctorate degree, which is an indication that the qualifications of academics in Turkey are insufficient. The association of Community Health Nursing Educators recommends that graduating PHN faculty seek graduate-level preparation in PHN with an emphasis on population-based practice and encourages doctoral degree nursing preparation (Collier et al. 2010). Although no data could be collected on the complete nursing curriculum for this study, the fact that the subject of PHN is restricted to only one semester’s course may be accepted as an indication that nursing school programmes are generally more focused on acute emergency treatment and nursing care services.
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Anecdotally, we know today that the practice of PHN and the education available in this branch differs from country to country, as the literature on this is insufficient. In the USA, Canada, the UK and other developed countries, PHN education has prescribed standards and competencies but in comparison the regulatory foundation is inadequate in developing countries. In Japan, undergraduate education in the area of PHN consists of a 3-year basic nursing curriculum after high school followed by an additional 1 year in special training in public health (Murashima et al. 1999).The number of nurses working in protective services in Latin America is insufficient and there are differences between countries (Nigenda et al. 2010). Moreover, PHN is defined in different ways between countries. Philibin et al. (2010) assert that there are more than 23 different definitions of the public health nurse. These definitions include, for example, ‘community health nurse’, ‘community health practitioner’, ‘primary healthcare nurse’, ‘visiting doctor’, ‘primary care psychiatric nurse’, ‘rural nurse’, ‘family nurse’, ‘district nurse’ and ‘visiting nurse’ (Nigenda et al. 2010). It is also predicted that there are different practices and different educational levels incorporated into the foundation of this definition. In any part of the world today, architects, engineers or physicians are perceived as members of universal professions. The duties they perform, their level of education are more or less standardized. Why should nurses and especially public health nurses be any different? The answer to this lies firstly in whether the nursing school curriculum defines the nature of nursing as a reflection of the philosophy of public health. Reducing PHN education to a single semester’s course within the general nursing curriculum makes it difficult for students to understand the philosophy behind public health. The nature of nursing itself overlaps one-to-one with the nature of public health (Savage & Kub 2009). It is unfortunate that curriculums have not incorporated the definition of nursing provided by the International Council of Nurses (ICN), which states, ‘Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles’ (ICN 2010). A single-semester course in PHN is inadequate to educate the philosophy and role of the nurse that is described in this definition. PHN needs to be integrated with all the other branches of nursing. Studying paediatric nursing, for example, it is not only learning how to care for the sick child but also how to protect and improve paediatric health that must be part of the curriculum. Another example, studying internal medicine
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nursing should not only be about the care and treatment of the sick adult, but also about how to protect and improve adult health. It is the researchers’ opinion that the reason nursing has not sufficiently developed in Turkey is because the curriculum of nursing education is focused more on treatment and nursing care services. Nurses graduating from this programme generally prefer working in the clinical environment but have a difficult time working in treatment and care services at the hospitals, where they experience work overload. Why is it that health promotion and illness prevention, a field to which nurses can greatly contribute, are not given the importance they deserve in nursing programmes? Why have nursing curriculums failed to develop in line with the ICN definition of nursing? These are some of the questions that have resulted from the research and that perhaps that nursing programmes are being modelled after medical school programmes. If we fail to educate nurses in accordance with the philosophy of public health, we will be defenceless against the negative forces of the health ‘reforms’, where the main objective is to seek material gain from health services. There will be no nursing professionals to stand up for public health and nurses graduating may not even have the qualifications necessary to be effective in a system that aims at health promotion and illness prevention. Turkey has already experienced such an example. The law passed in 1961 supporting the socialization of health services (Official Gazette of Republic of Turkey 1961) complied with the World Health Organization’s Declaration of Alma-Ata for the protection and promotion of health (WHO 1978). Unfortunately, political policies and the strong ambition to privatize health services prevented the implementation of this law. The necessary infrastructure was not built and ultimately the law was declared an unsuccessful endeavour, a failure. An important reason for the lack of success of Turkey’s socialization law is the way Turkey has been affected by the liberal ‘free-market’ polities arising out of globalization. Additionally, it is the researchers’ opinion, this law could not be implemented for the main reason that nurses and physicians have been educated to focus predominantly on acute and emergency care and treatment. As evidenced in this study, inadequate weight has been given to the protection and promotion of health in courses on PHN. Health prevention is studied in 84.5% of the schools and health promotion in only 65.5%. The time devoted to these two subjects is significantly inadequate. Carter et al. (2006) suggested that PHN education consist of public planning, public/population assessment, coordination and management, public health emergency preparedness and response, epidemiology and biostatistics, ethics, global health, health promotion, risk reduction and management, disease
Public health nursing content in Turkey
prevention, human diversity, illness and disease management, information and health care technology and core public health functions. Turkey experiences natural disasters at almost any time of the year. There is cause for concern when it is noted that the subject of public health emergency preparedness and response has been made a part of the PHN course in only 10.6% of schools. The subjects of epidemiology-biostatistics and ethics are usually offered as separate courses in the classic nursing curriculum and therefore their absence in the PHN syllabus cannot be interpreted as a deficiency of the programme of nursing education. A large majority of the participants reported problems with clinical placement sites in PHN education. Again, close to half of the respondents reported having no role models and also mentioned a shortage of instructors. The inadequacy in placement sites for practical education is an outcome of the family medicine system that was launched as part of the health transformation project. Our study discovered that there are too few schools in Turkey that offer graduate degrees in PHN. This is supported by the fact that the participants reported a shortage of instructors in this field. It is not difficult to conclude from the results of the study that academic inadequacy prevails not only in numbers but also in terms of competency. The number of students per instructor (34.04) is twice the mean 2008 OECD figure (15.8) (OECD 2010). Another issue is that instructors are not evenly distributed across schools. In almost half of the universities, there is only one instructor. The reason for this is that academics generally prefer working at the universities in the big cities.
Conclusion In conclusion, it can be said that there are problems in Turkey with regard to PHN education. The nursing school curriculum must be revised at a national level if PHN is to be revived and strengthened. Limitations
The most significant limitation in this study was that PHN education was assessed within its own context. Results would have been more illuminating if it could have been evaluated within the context of the whole of the nursing curriculum.
Conflicts of interest None.
Author contributions Study conception/design: HK, SA. Data collection and analysis: HK, SA.
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Statistical expertise: HK. Drafting of manuscript: HK, SA. Administrative/technical/material support: HK, SA, MNE. Supervision: MNE. Critical revisions for important intellectual content: MNE.
References Altay, A. (2007) Saglik hizmetlerinin sunumunda yeni acilimlar ve Turkiye acisindan degerlendirilmesi [The evaluation of new expansions and the provision of health care services in Turkey]. Sayistay Dergisi [Journal of Turkish Courts of Account], 64, 33–58. Carter, K.F., Kaiser, K.L., O’Hara, P.A. & Callister, L.C. (2006) Use of PHN competencies and ACHNE essentials to develop teaching-learning strategies for generalist C/PHN curricula. Public Health Nursing, 23 (2), 146– 160. Collier, J., et al. (2010) An association of community health nursing educators position paper. Public Health Nursing, 27 (1), 89–93. Education Committee of the Association of Community Health Nurse Educators (2010) Essentials of baccalaureate nursing education for entry-level community/public health nursing. Public Health Nursing, 27 (4), 371–382. Esin, M.N., Emiroglu, O., Aksayan, S. & Beser, A. (2008) Undergraduate occupational health nursing education in Turkey: a national survey. International Nursing Review, 55, 156–163. Feenstra, C. (2000) Community based and community focused: nursing education in community health. Public Health Nursing, 17 (3), 155–159. ICN (2010) Definition of Nursing. Available at: http://www.icn.ch/abouticn/icn-definition-of-nursing/ (accessed 19 June 2013). Last updated on Monday, 12 April 2010 21:38. Kurlowicz, L.H., et al. (2007) Graduate education in geropsychiatric nursing: findings from a national survey. Nursing Outlook, 55, 303–310. Levin, P.F., et al. (2008) Graduate education for advanced practice public health nursing: at the crossroads. Public Health Nursing, 25 (2), 176–193. Murashima, S., Hatomo, Y., Whyte, N. & Asahara, K. (1999) Public health nursing in Japan: new opportunities for health promotion. Public Health Nursing, 16 (2), 133–139. Nigenda, G., Valladares, L.M., Cooper, K. & Larios, J.A.R. (2010) Recent development in public health nursing in Americas. International Journal of Environmental Research and Public Health, 7, 729–750. OECD (2010) Education at a Glance 2009: OECD Indicators. Paris. Official Gazette of Republic of Turkey (1961) Saglik hizmetlerinin sosyallestirilmesi hakkinda kanun [The law of socialization of health services]. The Law number: 224. 12.01.1961/10705. (in Turkish). Official Gazette of Republic of Turkey (2004) Aile hekimligi pilot uygulamasi hakkinda kanun [The law of Pilot Implementation of Family Medicine]. The Law number: 5258. 09.12.2004/25665. (in Turkish). Official Gazette of Republic of Turkey (2007) Hemsirelik Kanunu [The Law of Nursing]. The Law number: 5634. 02.05.2007/26510. (in Turkish). Official Gazette of Republic of Turkey (2010) Hemsirelik Yonetmeligi [The Regulation of Nursing]. The Law number: 27515. 08.03.2010. (in Turkish). OSYM (Turkish Republic, Measurement, Selection and Placement Center) (2011) Guide to Higher Education Programs and Quotas. Available at:
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http://osym.gov.tr/belge/1-12584/2011-osys-yuksekogretim-programlarive-kontenjanlari-ki-.html/ (accessed 19 June 2013). Last updated: 20 July 2011. (in Turkish). Philibin, P., Brady, A.M. & Bepley, C. (2010) The role of the public health nurse in a changing society. Journal of Advanced Nursing, 66 (4), 743– 752. Robinson, J. (1999) The World Bank and The World Health Organization: international sources of ideas for health policy. In Interdisciplinary Perspectives on Health Policy and Practice: Competing Interests or Complementary Interpretations? (Robinson, J., Avis, M., Latimer, J. & Traynor, M., eds). Chapter 2, Churchill Livingstone, Edinburgh, pp. 53–80. Savage, C. & Kub, J. (2009) Public health and nursing: a natural partnership. International Journal of Environmental Research and Public Health, 6, 2843–2848. Stanhope, M. & Lancaster, J. (2003) Community & Public Health Nursing, 6th edn. Mosby, Philadelphia, PA, pp. 1–10. Uysal, A. (2005) Saglikta donusum projesi kapsaminda birinci basamak saglik hizmetlerinde hemsirelik nerede? [Where does nursing stand in
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primary healthcare services within the framework of the Health Transformation Project?]. Toplum Ve Hekim [Public and Physician], 20 (6), 448–454. (in Turkish). WHO (1978) Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata. Available at: http://www.who.int/publications/ almaata_declaration_en.pdf/ (accessed 10 May 2013). Yavuz, M. (2004) Nursing doctoral education in Turkey. Nurse Education Today, 24, 553–559.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site Table S1 Frequencies and means of public health nursing topics in undergraduate nursing education Table S2 Problems related to public health nursing education according to participants
Education
Public health nursing education in Turkey: a national survey H. Kadioglu1
RN, PhD, S.
Albayrak2
RN, PhD
& M.N. Esin3
RN, PhD
1 Assistant Professor, Department of Community Health Nursing, Health Science Faculty, Marmara University, 2 Assistant Professor, Division of Nursing, Health Science Faculty, Kırıkkale University, 3 Associate Professor, Department of Community Health Nursing, Florence Nightingale Nursing Faculty, Istanbul University, Istanbul, Turkey
KADIOGLU H., ALBAYRAK S. & ESIN M.N. (2013) Public health nursing education in Turkey: a national survey. International Nursing Review 60, 536–542 Aim: To investigate public health nursing content in undergraduate and postgraduate programmes in Turkey. Methods: This study included all of the nursing schools in Turkey that provide university level education. The data were collected through a self-administered questionnaire designed to identify the existing status of undergraduate and postgraduate public health nursing education between February 2011 and June 2011. The questionnaire was completed only by the head of the department of public health nursing in each school. Data were analysed with descriptive statistics using SPSS for Windows 17.0 software. Results: The study achieved a response rate of 72.5%. All participants reported offering a course in public health nursing in their undergraduate programmes. Fourteen (24.1%) participants reported offering Master of Science degrees in public health nursing. Seven (12.1%) participants reported offering doctorate degrees in public health nursing. In the responding schools, the public health nursing course was given in one semester (14 weeks) for an average of 5.54 ⫾ 1.43 h/week for theory and an average of 13.48 ⫾ 5.11 h/week for clinical practice. Of the participants, 43 (74%) reported problems related to public health nursing education. Conclusion: There are problems in Turkey with regard to public health nursing education. The nursing school curriculum must be revised on a national level if public health nursing is to be revived and strengthened. Keywords: Postgraduate Education, Public Health Nursing, Undergraduate Education
Introduction In the early 21st century, factors such as the rapid increase in the world population, scientific and technological developments, and the steady decrease in the resources needed for human existence have brought about issues that include migrations, unemployment, nutritional problems, endemic and
Correspondence address: Mrs Hasibe Kadioglu, Department of Community Health Nursing, Marmara University, Tibbiye cad. No: 40, Haydarpasa-Istanbul 34668, Turkey; Tel: 00902164181606/1134; Fax: 00902164183773; E-mail: [email protected].
Source of funding: None.
© 2013 International Council of Nurses
pandemic epidemics, mother and child health and public health issues. These are problems not only for any one country, but for all countries. Issues have become global. Primary health care and the public health nurses that provide this care play a key role in finding solutions to these problems. Public health nursing (PHN) is a specialized field within the nursing profession. It is a branch of nursing that is focused on the population since its practitioners often work with members of the general public who are not in hospitals or other healthcare institutions. Its practitioners also focus on the relationship between the health of the population and the environment, concentrating on physical, biological and socio-cultural factors that play a role in meeting public health needs (Stanhope & Lancaster 2003).
536
Public health nursing content in Turkey
It is unfortunate that the liberal and free-market policies that emerged out of the globalization that took place after World War II have pushed primary healthcare services into the background. In an atmosphere where liberal policies are dominant, international monopolies find no legal obstacle to prevent them from producing their products at the lowest cost and selling these at the highest profit margins. This is turning the entire world into a free market zone. The developments that we are witnessing today in healthcare services all around the world are a consequence of such policies. Health care is seen as a most profitable area of business, in particular, diseases are the elements that constitute the source of profit in healthcare services. Liberal policies have resulted in a focus on private health services where the ‘user pays’ for health services. In such an environment, multinational corporations that produce and distribute pharmaceuticals and products of medical technologies on a global scale have become so powerful that they are allowed to shape health economies and trends. Compounding these global policies, the World Bank and the International Monetary Fund try to energize the global economy by extending loans to underdeveloped and developing countries. They seek in return that these countries adopt reforms that lead to the privatization of their healthcare services (Altay 2007; Robinson 1999). Thus, the services provided by government and social state have started to be replaced by private sector services that accept the sovereignty of the free market. General nursing and PHN education in Turkey
Nursing schools began to open in Turkey after World War I and the first nursing school was established in 1920. In 1925, the first nursing high school of the Republican Period opened, and in 1955, the first 4-year college-level nursing programme in Europe started in Turkey under the name of Ege (Aegean) University College of Nursing. A master’s programme was instituted in 1968, followed by the establishment of a doctoral programme in 1972 (Yavuz 2004). PHN is an essential content in undergraduate nursing programmes in Turkey. Specialty programmes in PHN curriculums exist at the master’s and doctoral levels. A master’s programme in PHN was started in Turkey in 1982; the doctoral programme was launched in 1985. PHN in Turkey were identified for the first time in 1961 in the ‘Regulations on the Execution of Services in Regions where Health Services have been Socialized’, based on Law no. 224 (Official Gazette of Republic of Turkey 1961) and public health services continued under these regulations until 2004. Turkey began to feel the effects of globalization more closely after 1980. Every government coming into office after 1980 included healthcare reform in their programmes. These reforms
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were never implemented however until 2004. In that year, in return for the loans extended by the World Bank, Turkey began to implement a series of health reforms under the name of ‘Health Services Transformation’ (Official Gazette of Republic of Turkey 2004). These reforms were completed in 2012. The reforms have three main components. The first is the transition to the family physician system in primary healthcare services. The second is related to making the state hospitals autonomous and the third to the transition into a general health insurance plan. This new system, in which the system of family medicine has been incorporated into primary healthcare services, has affected the services and the education of public nurses. The system operates with private medical professionals working as family physicians accompanied by nurses who are considered health workers. In the family medicine system, the nurse is designated as a ‘family health attendant’ working with the family health doctor. A family health attendant may be a nurse, midwife, emergency medical technician or similar professional. Thus nurses, who had a fundamental role in basic healthcare services within the law passed in 1961, have been neglected and not made a significant part of the new family medicine model (Uysal 2005). Together with these changes, two other developments have occurred with respect to nursing in Turkey. The first is the Law on Nursing, passed in 2007 (Official Gazette of Republic of Turkey 2007), and the second is the Regulations on Nursing initiated in 2010 that sets forth the duties, powers and responsibilities of nurses (Official Gazette of Republic of Turkey 2010). In these regulations, the duties, powers and responsibilities of homecare nurses, mother and child health and family planning centre nurses, community mental health centre nurses, occupational health nurses, school health nurses and penitentiary nurses were defined under the general heading of PHN but the duties, powers and responsibilities of the public health nurse as a separate entity was not defined. In fact, the new health reform does not even include public health nurses. Under these circumstances, the new health reforms and new arrangements question what kind of education a public health nurse must have. PHN education in the 4-year undergraduate nursing programme in Turkey consists of a single-semester course. There are no postgraduate certification programmes available. It is important for the development of public health in Turkey to establish standards and competencies in PHN education. There is no data available at this time about which subjects are included in undergraduate and postgraduate programmes in Turkey or about the duration of PHN education in general. Before regulations can be initiated, the present status of public health education must first be determined. A review
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must be made of whether there are differences of curriculum between schools, what qualifications are held by educators, the length of current theoretical and practical PHN education programmes, curriculum content, the different scopes of practice and what problems the health reform has brought to nursing school programmes. This article reports the findings of a national survey of PHN in undergraduate and postgraduate nursing programmes. This was the first study of its kind conducted at a national level in Turkey to evaluate the PHN education provided at the undergraduate and postgraduate levels. In addition, this survey was intended to provide baseline data on the current status of PHN in the undergraduate–postgraduate nursing curriculum to provide some comparative basis for future studies. The aim of the study was to investigate Turkish PHN education. This was addressed by the study questions: 1 Which courses are included and what length of time is given to PHN courses in undergraduate and postgraduate education? 2 What are the qualifications of the educators who teach PHN classes in undergraduate and postgraduate education? 3 What are some of the problems faced by educators in the nursing school programmes?
Methods Design and sample
This quantitative descriptive study included all of the nursing schools in Turkey (n = 92) that provide university level education (OSYM 2011). Since 12 of the schools listed were newly established institutions, these were excluded from the study. Permission for the study was obtained from the relevant university presidents by the president of the university at which the first author of the present study works. The selfadministered questionnaires were completed only by the heads of the departments of PHN in each school. A total of 80 schools of nursing were therefore invited to participate with questionnaires distributed via e-mail. Email addresses for the heads of the departments of PHN were updated from the relevant university website. A brief letter outlining the goals of the questionnaire and details of the study was included with each email invitation. An email reminder and a paper copy of the questionnaire were also sent to prospective respondents in the month following the initial distribution of the surveys in an effort to maximize the response rate. The institutional review board of Semahat Arsel Nursing Education and Research Center, Koç University, Istanbul, Turkey, approved this study.
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Measures
The data were collected through self-administered questionnaire designed to identify the existing status of undergraduate and postgraduate PHN education between February 2011 and June 2011. The questionnaire was based on previous studies and literature (Carter et al. 2006; Education Committee of the Association of Community Health Nurse Educators 2010; Esin et al. 2008; Feenstra 2000; Kurlowicz et al. 2007; Levin et al. 2008) as well as on the researcher’s practical experience. The questionnaire comprised four parts with a total of 21 items. In the first section, there were four items that asked for quantitative information and details of the qualifications of the academic faculty and the school. In the second section, there were five items that evaluated the topics taught and the length of PHN in undergraduate education. In the third section, there were ten items that evaluated the names of the courses and the length of PHN in postgraduate education. The fourth section comprised two items that asked the heads of the PHN departments their opinion about problems and solutions in PHN education.
Data analysis
Data were analysed with descriptive statistics using SPSS for Windows 17.0 software (SPSS Inc., Chicago, IL, USA). Similar answers to the open-ended questions were grouped together and every group was given a numerical code. These codes were entered into the program as data.
Results Of the 80 schools surveyed, 22 did not respond; the number of respondents was 58, making the response rate 72.5% (n = 58). All schools reported offering a course in PHN in their undergraduate programmes. Fourteen (24.1%) schools reported offering Master of Science degrees in PHN. Seven (12.1%) schools reported offering PhDs in PHN (Table 1).
Academic qualifications of lecturers
There were 132 lecturers responsible for teaching PHN in the 58 schools. The average number of instructors per school was 2.2. Twenty-seven (46.6%) schools had only one instructor. It was found that the average number of students per instructor was 34.04. Of the faculty members, ten (8%) were professors, five (4%) were associate professors, 40 (32%) were assistant professors; 56 (42%) had master’s degree; 21 (16%) had only bachelor’s degrees. Ninety-two (70%) of the academics had a degree in the area of PHN. The others had degrees in other nursing
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Table 1 Characteristics of public health nursing undergraduate and postgraduate education in Turkey Programmes
n (%)
Course
n
Mean of TCD
Mean of TED
Mean of PED
Undergraduate Master of Science
58 (100) 14 (24.1)
Public health nursing All courses Concepts and theory Nursing research Biostatistics Health promotion Health education Home care Epidemiology All courses
58 – 14 9 8 8 5 5 4 –
266.44 424.93 164.73 38.50 34.00 47.00 39.20 56.00 45.50 585.20
77.60 244.7 71.40 38.50 34.00 24.50 22.40 22.40 31.50 341.60
188.84 180.23 93.33 – – 22.50 16.80 33.60 14.00 243.60
Doctorate
7 (12.1)
PED, practical education duration; TCD, total course duration; TED, theoretical education duration.
branches (women’s health, epidemiology, paediatrics, health education, etc.).
the findings related to the classes in these programmes would not provide significant results.
Undergraduate education
Problems in PHN education
In the responding schools, the PHN course was given in one semester (14 weeks) for an average of 5.54 ⫾ 1.43 h/week (range 2–9 h) for theory and an average of 13.48 ⫾ 5.11 h/week (range 4–32 h) for clinical practice. PHN topics in undergraduate nursing education with the highest theoretical education duration percentages were ‘Introduction to PHN’ (93.1%), ‘Health policies’ (93.1%), ‘Elderly health’ (93.1%), ‘Home visiting’ (91.4%) and ‘School health nursing’ (91.4%). The respondents worked at a variety of clinical placement sites to practice PHN. More than two-thirds (74%) of the clinical placement sites were family health centres and 51% of the programmes utilized school health offices for their clinical placements. Another 35% made use of rest homes, 33% made placements in public health centres and 32% in occupational health offices for practical education. Ambulatory, home care and other clinical placement sites were used by approximately one-fifth of the respondents. It must be noted here that many programmes reported making multiple types of clinical sites available for their PHN courses.
Of the participants, 43 (74%) reported problems related to PHN education. Participants said that the most important problems were the lack of quality clinical sites (74%), the lack of role models in clinical settings (43%) and an insufficient number of qualified lecturers (41%).
Graduate education
Because the number of schools offering postgraduate and doctoral programmes was very few, the researchers concluded that
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Discussion This study tried to identify and describe the current status of undergraduate and postgraduate programmes in PHN in Turkey. It was found that more than half of the academics in the field (58.4%) do not have a doctorate degree, which is an indication that the qualifications of academics in Turkey are insufficient. The association of Community Health Nursing Educators recommends that graduating PHN faculty seek graduate-level preparation in PHN with an emphasis on population-based practice and encourages doctoral degree nursing preparation (Collier et al. 2010). Although no data could be collected on the complete nursing curriculum for this study, the fact that the subject of PHN is restricted to only one semester’s course may be accepted as an indication that nursing school programmes are generally more focused on acute emergency treatment and nursing care services.
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Anecdotally, we know today that the practice of PHN and the education available in this branch differs from country to country, as the literature on this is insufficient. In the USA, Canada, the UK and other developed countries, PHN education has prescribed standards and competencies but in comparison the regulatory foundation is inadequate in developing countries. In Japan, undergraduate education in the area of PHN consists of a 3-year basic nursing curriculum after high school followed by an additional 1 year in special training in public health (Murashima et al. 1999).The number of nurses working in protective services in Latin America is insufficient and there are differences between countries (Nigenda et al. 2010). Moreover, PHN is defined in different ways between countries. Philibin et al. (2010) assert that there are more than 23 different definitions of the public health nurse. These definitions include, for example, ‘community health nurse’, ‘community health practitioner’, ‘primary healthcare nurse’, ‘visiting doctor’, ‘primary care psychiatric nurse’, ‘rural nurse’, ‘family nurse’, ‘district nurse’ and ‘visiting nurse’ (Nigenda et al. 2010). It is also predicted that there are different practices and different educational levels incorporated into the foundation of this definition. In any part of the world today, architects, engineers or physicians are perceived as members of universal professions. The duties they perform, their level of education are more or less standardized. Why should nurses and especially public health nurses be any different? The answer to this lies firstly in whether the nursing school curriculum defines the nature of nursing as a reflection of the philosophy of public health. Reducing PHN education to a single semester’s course within the general nursing curriculum makes it difficult for students to understand the philosophy behind public health. The nature of nursing itself overlaps one-to-one with the nature of public health (Savage & Kub 2009). It is unfortunate that curriculums have not incorporated the definition of nursing provided by the International Council of Nurses (ICN), which states, ‘Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles’ (ICN 2010). A single-semester course in PHN is inadequate to educate the philosophy and role of the nurse that is described in this definition. PHN needs to be integrated with all the other branches of nursing. Studying paediatric nursing, for example, it is not only learning how to care for the sick child but also how to protect and improve paediatric health that must be part of the curriculum. Another example, studying internal medicine
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nursing should not only be about the care and treatment of the sick adult, but also about how to protect and improve adult health. It is the researchers’ opinion that the reason nursing has not sufficiently developed in Turkey is because the curriculum of nursing education is focused more on treatment and nursing care services. Nurses graduating from this programme generally prefer working in the clinical environment but have a difficult time working in treatment and care services at the hospitals, where they experience work overload. Why is it that health promotion and illness prevention, a field to which nurses can greatly contribute, are not given the importance they deserve in nursing programmes? Why have nursing curriculums failed to develop in line with the ICN definition of nursing? These are some of the questions that have resulted from the research and that perhaps that nursing programmes are being modelled after medical school programmes. If we fail to educate nurses in accordance with the philosophy of public health, we will be defenceless against the negative forces of the health ‘reforms’, where the main objective is to seek material gain from health services. There will be no nursing professionals to stand up for public health and nurses graduating may not even have the qualifications necessary to be effective in a system that aims at health promotion and illness prevention. Turkey has already experienced such an example. The law passed in 1961 supporting the socialization of health services (Official Gazette of Republic of Turkey 1961) complied with the World Health Organization’s Declaration of Alma-Ata for the protection and promotion of health (WHO 1978). Unfortunately, political policies and the strong ambition to privatize health services prevented the implementation of this law. The necessary infrastructure was not built and ultimately the law was declared an unsuccessful endeavour, a failure. An important reason for the lack of success of Turkey’s socialization law is the way Turkey has been affected by the liberal ‘free-market’ polities arising out of globalization. Additionally, it is the researchers’ opinion, this law could not be implemented for the main reason that nurses and physicians have been educated to focus predominantly on acute and emergency care and treatment. As evidenced in this study, inadequate weight has been given to the protection and promotion of health in courses on PHN. Health prevention is studied in 84.5% of the schools and health promotion in only 65.5%. The time devoted to these two subjects is significantly inadequate. Carter et al. (2006) suggested that PHN education consist of public planning, public/population assessment, coordination and management, public health emergency preparedness and response, epidemiology and biostatistics, ethics, global health, health promotion, risk reduction and management, disease
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prevention, human diversity, illness and disease management, information and health care technology and core public health functions. Turkey experiences natural disasters at almost any time of the year. There is cause for concern when it is noted that the subject of public health emergency preparedness and response has been made a part of the PHN course in only 10.6% of schools. The subjects of epidemiology-biostatistics and ethics are usually offered as separate courses in the classic nursing curriculum and therefore their absence in the PHN syllabus cannot be interpreted as a deficiency of the programme of nursing education. A large majority of the participants reported problems with clinical placement sites in PHN education. Again, close to half of the respondents reported having no role models and also mentioned a shortage of instructors. The inadequacy in placement sites for practical education is an outcome of the family medicine system that was launched as part of the health transformation project. Our study discovered that there are too few schools in Turkey that offer graduate degrees in PHN. This is supported by the fact that the participants reported a shortage of instructors in this field. It is not difficult to conclude from the results of the study that academic inadequacy prevails not only in numbers but also in terms of competency. The number of students per instructor (34.04) is twice the mean 2008 OECD figure (15.8) (OECD 2010). Another issue is that instructors are not evenly distributed across schools. In almost half of the universities, there is only one instructor. The reason for this is that academics generally prefer working at the universities in the big cities.
Conclusion In conclusion, it can be said that there are problems in Turkey with regard to PHN education. The nursing school curriculum must be revised at a national level if PHN is to be revived and strengthened. Limitations
The most significant limitation in this study was that PHN education was assessed within its own context. Results would have been more illuminating if it could have been evaluated within the context of the whole of the nursing curriculum.
Conflicts of interest None.
Author contributions Study conception/design: HK, SA. Data collection and analysis: HK, SA.
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Statistical expertise: HK. Drafting of manuscript: HK, SA. Administrative/technical/material support: HK, SA, MNE. Supervision: MNE. Critical revisions for important intellectual content: MNE.
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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site Table S1 Frequencies and means of public health nursing topics in undergraduate nursing education Table S2 Problems related to public health nursing education according to participants
