Social_Determinants_to_Health

Health Communications: Nursing Education for Increased Visibility and Effectiveness MARY CHAFFEE, MS, RN,CNA, CCRN The media play an influential role in American society. The challenge for health professionals, including nurses, is to translate and transmit complex health information for the public through many channels. Although nurses are trained to be effective communi- cators in practice, a recent study demonstrates that nurses are virtually invisible in the media. This lack of visibility limits nursing's ability to communicate impor- tant health information, impedes nursing's ability to define its role and contributions in the health care delivery system, and restricts nursing's ability to advocate for health policy. One option to improve nurses' ability to communicate effectively in all media venues is to integrate health communications content into nursing programs, which would provide nurses with the opportunity to develop advanced communica- tion skills, media expertise, and new strategies for educating the public. Health communications pro- grams exist in several colleges and universities, but not within nursing programs. Because nursing cur- ricula are in a period of transition as changes in the health care environment are accommodated, health communications courses could be integrated into nursing programs as elective courses, graduate certifi- cate programs, or a field of graduate study. Without creative educational strategies, nursing will remain invisible to the public and ineffective in its ability to influence the health care environment. (Index words: Curriculum development; Health communications; Health writing and editing; Media training; Media visibility) J Prof Nurs 16:31-38, 2000. Copyright. 2000 by W.B. Saunders Company A REMARKABLE book about nurses, Life Sup- port--Three Nurses on the Front Lines, was published in 1997. It received glowing reviews from nurses and the national press. The author captured the essence of modern nursing through the stories of three nurses in Boston, MA. To write so eloquently about nursing's work, one would expect to find that the *Semor Health Program Analyst, Office of the Assistant Secre- tary of Defense for Health Affairs, TRICARE Management Activity, Falls Church, VA. Address correspondence and reprint requests to Ms Chaffee: 8601 Lime Kiln Court, Montgomery Village, MD 20886. Copyright . 2000 by W.B Saunders Company 8755-7223/00/1601-0008510.00/0 author is a nurse, but the author, Suzanne Gordon, is a journalist, not a nurse. Why did it take someone who is not a nurse to communicate nursing's story so effectively' Nursing: Invisible and Silent Life Support is a rare example of nursing receiving the thoughtful attention of the popular press. A study at the University of Rochester School of Nursing (Woodhull Study, 1998) concluded that nurses and the nursing profession are essentially invisible to the media and, consequently, to the American public. The Woodhull Study found that nurses were cited as sources only 4 per cent of the time in more than 2,000 health-related articles in 16 major news publications. This figure is consistent with an earlier study that found nurses were almost entirely absent as sources of information in the media, even in areas that depend heavily on nursing (Buresh, Gordon, & Bell, 1991). This earlier study concluded that nurses are not among those who count in news coverage and found the consequences of nursing's silence in the media concerning. Buresh et al. noted that the press has an obligation to inform the public, and by ignoring nursing's voice, the accuracy of reporting on health care is suspect. It is difficult for a group to have influence on public policy and the allocation of resources unless it can be seen and heard as a part of the discussion. Gordon (1997) also addressed this problem in Life Support. She wrote that reporters rarely cover nursing innovations, use nurses as sources, or report on nursing research. When reporters and politicians consult health care experts, they invariably turn to physicians, physician organizations, or health care policy experts, all of whom regard health care through the lens of medicine or economics. The media include television, radio, print (newspa- pers, magazines, newsletters, and billboards), and electronic, and their influence cannot be underesti- mated. The media's power arises from their ability to Journal ofProfessionalNursing, Vol 16, No 1 (January-February), 2000: pp 31-38 MARY CHAFFEE get a message or information to a large number of people or to key people. What the media do or do not cover influences what issues receive the attention of the public and the policymakers (Mason, Glickstein, & Dodd, 1998). Health stories may be distorted by the media through specific reporting styles, choice of language, selection of sources, and the use of metaphor. Sensa- tionalized treatment of crises, such as "flesh-eating" bacteria, mad cow disease, and Ebola virus, may leave the public apathetic. Moeller (1999) described this phenomenon as "compassion fatigue," a public re- sponse to tabloid-style, crisis-oriented reporting that emphasizes the sensational, macabre, and personal. The potential for distorted health stories in the media--combined with the lack of input from nurses, the largest segment of the health care workforce in the United States--is worrisome. Nurses communicate expertly with patients, fami- lies, colleagues, and a wide variety of health care professionals. Although nurses are trained to be effective communicators in clinical practice, few pro- ceed to active involvement in communications at another level: authoring and editing articles and books, advocating publicly for health policy, develop- ing media strategms for health education campaigns, and providing insight as media experts. Gordon (1999) suggested that nurses are socialized to avoid trumpeting their individual and collective contributions to the health care system. She argues that a pernicious double standard exists where physi- cians are hailed for their heroic efforts to save patients, whereas nurses are warned against being boastful. Gordon (1999) challenged nurses to "Explain their work. The stories will move and enlighten people and shouldn't be kept secret" (p. 63). The complexities of the hved experiences of nurs- ing-professional, social, physical, and emotional-- are unquestionably best understood by the nurses who live it. However, are nurses prepared to interpret their work so that others understand it' Developing educa- tion programs in health communications is one option to prepare nurses to become more visible to the public, more effective in communicating nursing's messages to large audiences, and more skilled in communicating public health messages. Health com- munications education would permit nurses to de- velop expertise in health journalism leadership, design- ing effective media campaigns, and communicating clearly to the public the contributions that nurses make to health and wellness. Definition of Health Communications Dr Scott Ratzen, editor of the Journal of Health Communication, stated that it was the modern public's thirst for accurate, timely health information that led to the formation of the health communications field and the training of professional communicators of health knowledge (1998). The Emerson College-Tufts University Program in Health Communications (1998) defines health communication as the art and tech- nique of crafting messages, informing, influencing, and motivating institutional and public awareness about important health issues. Its scope includes disease prevention and health promotion, health care policy and business, and enhancement of the quality of life and health of individuals within the commu- nity. When a significant health concern is identified by public health officials, advocacy groups, or political forces, health communicators are called on to develop communications strategies to raise awareness and contribute to the reduction or elimination of the health concern. Formal health communications cam- paigns are developed in six stages: planning and strategy selection, selection of channels and material, development of materials and pretesting, implementa- tion, assessment of effectiveness, and feedback to redefine the program (McGrath, 1995). The primary challenge for health communicators, nurses included, is to distill a huge volume of health information into a format for public consumption. Eggner (1998) noted that the mass of emerging biomedical knowledge is overwhelming, with approxi- mately 4,000 professional journals currently indexed on MEDLINE. He asserted that there is a gap between the expanding volume of health information and public health partly due to the difficulty in dispensing the information to the lay public. Historical Efforts to Educate Nurses in Health Communications The need for effective communication in nursing has long been acknowledged. In a 1940 article in the American Journal of Nursing, Brown wrote, "One (nurse) may be applying for a position, may be writing letters for a well-educated patient for whom she is on special duty, another may be preparing a talk to be presented to a group of nurses, another may be interviewing legislators in regard to legislation needed in nursing. Is there any one of these nurses who has HEALTH COMMUNICATIONS EDUCATION not the need of faultless diction and ease of expres- sion'" (p. 1256). By 1940, many articles had appeared in the nursing hterature advising nurses how to write and have manuscripts published. The goal of writing was for "nurses to interpret to other nurses and the lay pubhc the goals and aspirations of the nursing profes- sion" (Brown, 1940, p. 1260). In 1950, the American Journal of Nursing Com- pany established the Mary M. Roberts Fellowshxp in journalism (1960). The recipient was granted up to $3,000, in addition to tuition, to defray the cost of one academic year of study in journalism. The purpose of the fellowship was to help professional nurses develop the skills needed to write about nursing and to interpret health care information effectively to other professional groups and the general public ("The 1961 Roberts Fellowship," 1960). Copp (1997) described a writer's workshop conducted in the early 1960s by the American Journal of Nursing Company and Boston University as a "novel idea and effectively contrived" (1997). In 1981, Diers exhorted nurses to write and commented that, "We now have in nursing several generations of nurses who have little training in writing" (p. 4). She added that it is absolutely crucial for nurses to write about nursing and patient care, yet none of the three kinds of programs that prepare nurses emphasizes writing as a necessary skill. The last two decades have seen some schools of nursing implement courses on "how to get pub- lished," writing workshops offered at nursing confer- ences and meetings--and some motivated nurses have sought out mentoring and other individual learning experiences. The outcome of this haphazard approach is now apparent in the results of the Woodhull study: despite these activities, the contributions of nursing remain invisible to the public. Dracup and Bryan- Brown (1998) found this baffling considering the central role the 2.5 million American nurses play in the health care system. Integrating Health Communications Into Nursing Curricula If we judge previous efforts ineffective in preparing nurses to be influential in the media, what are possible solutions' The timing is right to consider creating innovative academic programs for nurses in health communications. Curriculum revision is underway in many nursing programs throughout the United States to address changes in the health care delivery system. Kupperschmidt and Burns (1997) suggested that curriculum revision provides faculty with an opportu- nity to "envision the new" (p. 90). Long (1994) added that if nurses are to assume appropriate leadership functions in future health care roles, nursing educa- tion programs must respond now by evaluating and revising the ways in whmh professional nurses are prepared. Sullivan (1997) addressed the need for diverse and innovative curricula and suggested that colleges and universities must be able to respond to opportunities as well as serve as catalysts to create a new vision. She added that students are demanding relevant courses, applicable skills, and value for their time and money. Finally, she contended that tomorrow's nurses must be able to think critically and to find information and communicate it effectively. Health communications courses for nurses are a creative response to a demon- strated need and would provide students with relevant and valuable skills. The Design of Health Communications Programs Several options exist for the design of health communications content in nursing programs: elec- tive courses at the baccalaureate or graduate level and certificate or degree programs at the graduate level. An important component in the development of these options is the use of partnerships and alliances with other schools within an institution (such as public health, journalism, and communications) or with other institutions. These alliances enhance educational design using existing resources. A distinct advantage of joint academm programs is the blending of institu- tional strengths and expertise to meet the goals for a specific program (Quinless, Elliot, & Saiff, 1997). ELECTIVE COURSES IN HEALTH COMMUNICATIONS Elective courses in health communications may be designed to utilize regional resources and to reflect the nursing school's unique mission and faculty strengths. Individual courses may be designed for the baccalaure- ate or graduate level. Content might include the following: . conceptual frameworks for health communica- tions, . the role of nurses and nursing in health communications, MARY CHAFFEE . health journalism, writing, and reporting, . health information in the media, . media strategies for nurses, . ethical issues in health communications, . technology in health communications, and . health behavior and health communications. CERTIFICATE PROGRAMS IN HEALTH COMMUNICATIONS A certificate program provides graduate nursing students the opportunity to gain expertise in health communications theory and practice. The combina- tion of two to three core health communications courses and two to three electives permits students to complete a certificate program most relevant to their individual needs. One example of this type of program is offered at Johns Hopkins University. The Health Communica- tions Certificate Program is open to graduate students enrolled in a program in the School of Hygiene and Public Health. Two levels of competency are offered. The basic-level certificate program is designed for students who desire a general background in health communications. The advanced-level program is of- fered for students who desire to pursue more sophisti- cated public health applications of communications theory and practice and to prepare students to con- duct research in health communications. Courses offered in the Johns Hopkins Health Communications Certificate Program include Health Communications in the 1990s and Beyond, Commu- nication Network Analysis for Public Health, Theory and Research in Health Communications, Interper- sonal Influence in Medical Care, Communication Strategies for Health Education and Health Promo- tion, and Seminar in Community-wide Health Com- munications Programs. GRADUATE PROGRAMS IN HEALTH COMMUNICATIONS Like other recent innovations in graduate nursing education, such as nursing informatics and nursing health policy, the nursing education program that opts to develop the first nursing-based health communica- tions program could set a standard, gain significant publicity, and provide a unique educational opportu- nity for students. Colleges and universities with journalism, public health, or communications pro- grams could identify courses to be integrated into an innovative health communications curricula. Propri- etary courses could then be designed based on the current literature, modeled after existing health corn- munications courses, or developed with the guidance of experts in the field. Sites for student internships could be identified in health service organizations, public health agencies, and in health publishing, health marketing, and health communications agen- cies in the school's geographic region. One example of a graduate degree program in health communications is at Emerson College and Tufts University School of Medicine. In a joint aca- demic enterprise, the schools offer a 48-credit master of arts degree in health communications. The program may be completed in 2 years on a full-time basis or in up to 5 years on a part-time basis. Required and elective courses in the program are listed in Table 1. Alternative Learning Opportunities in Health Communications No nursing-based programs in health communica- tions exist yet, and few academic programs in other professional schools are available. To meet the current learning needs of nurses, it is important to scan the environment for alternative learning opportunities. Most options currently available target only a particu- lar area within health communications, such as media training, health reporting, or health writing and editing. Until more health communications courses, and certificate and degree programs become available, alternative learning opportunities will be valuable for nurses. TABLE 1. Emerson College--Tufts University Graduate Program in Health Communications Required courses Advanced Professional Communication Communication Theory Research Methods Med~a Strategies for the Health Professional Health Behavior and Public Pohcy Epldemlology-B~ostat~stlcs Reading and Interpreting the Medical Literature Public Health and Health Care Dehvery Systems Ethical Issues in Health Communications New Technology in Health Communications Seminar ~n Health Communtcat~ons/Apphed Learning Project Electwe courses Writing for PublLc Relations and Pubhc Affairs Advanced Polhng and Survey Techniques Poht~cal Economy, Ethics, and the Enwronment Advanced Interpersonal Communlcat~ons Theory Intercultural Commun~catlon Community Health Occupational and Environmental Health Environmental Law Data from Emerson-Tufts Program in Health Communications (1998) HEALTH COMMUNICATIONS EDUCATION MEDIA TRAINING Media training is available from commercial enter- prises. Media training acknowledges that reporters have a significant advantage over the source in an interview situation and aims to provide the source with the opportunity to develop the skills needed to effectively handle an interview or other media appear- ance. Susan Peterson Productions, Inc, a media train- ing venture, begins training with Communications Theory 101, which provides education on word choice, voice tone, and body language as well as more advanced strategies for dealing with "zinger" questions or a media "ambush." The American College of Emergency Physicians recently paid Susan Peterson Productions, Inc, $15,000 to provide a 1-day training program, and a 1-day follow-up at a later date, for eight physicians and one staff member (Farhi, 1998). RELATED ACADEMIC PROGRAMS The University of Chicago offers an eight-course certificate program in medical writing and editing through its publishing program in the Graham School of General Studies (1998). Reqmred courses in the program include the following: . Medical Editing, . The Structure of the Journai Article, . Scientific and Medical Bibliographic Re- sources, . The Internal Logic of Medical Writing, . Medical Ethics in Medical Writing, . Understanding and Interpreting Medical Sta- tistics, and . Presentatmn of Data in Charts and Tables. Electives offered in the program are Marketing Communications and Pharmaceutical Writing (Uni- versity of Chicago, 1998). At schools where no health communications courses are available, faculty may advise nursing students to consider electives in writ- ing, English, journalism, editing, marketing, or com- municanons. CONFERENCES AND MEETINGS A variety of professional meetings, including the American Nurses Association 1998 Biennial Conven- tion and the American Nurses Association 1999 House of Delegates meeting, have included programs on media strategies. A 1-day media relations program, entitled "Cutting Through the Clutter: Increasing Media Coverage of Nurses and Nursing Research," was presented in Washington, DC, on October 23, 1998. Sponsored by the National Institute for Nursing Research, the National Institutes for Health, Sigma Theta Tau International, the American Association of Colleges of Nursing, and the American Organization of Nurse Executives, the program focused on enhanc- ing the public's understanding, through the media, of nursing and nursing research. Rodale Press conducted a health forum entitled "Health Information in the Media: Dispensing Confu- sion'" in Bethlehem, PA, on November 10, 1998. A panel of notable journalists discussed how the media reports health information, consumer perception of information, and how health research becomes health reporting. The American Medical Writer's Association (AMWA) conducts an annual conference with exten- sive continuing education offerings. The 1998 confer- ence, "Communicating About Health in a Changing World," provided workshops on scriptwriting for TABLE 2. Health Communications Resources Resource and Contact Information Content American Med/ca/ Writers The Amencan Medical Writers Association Journal (301 - Association Journal is pub- 493-0003, www amwa org) lished quarterly Artfcles focus on topics ~n health writing and health commu- nications. The assoclatFon offers regional workshops and an annual conference for health writers American Pubhc Health Asso- The American Pubhc Health ciation (202-789-5677, Association offers an intern- www apha org) ship in health communica- tions Nurse Author & Editor (303-This quarterly newsletter for 988-0056, http//mem- nurse authors, editors, and bers aol com/suzannehl/ edJtonal board members nasub htm) provides content on a variety of writing and editing topics ONLINE Nursing Edltors This webslte, maintained by (http//members aol com/ Hall Johnson Communica- suzannehl/naed htm) tions (publisher of Nurse Author & Editor) offers hypertext links to more than 100 nursing journal and book editors The Journal of Health Com- This peer-rewewed quarterly munications (www aed org/ pubhshes research, essays, Ihealthcom) and book rewews on social marketing, interpersonal to mass media communica- tions, polrcymaklng, and health education MARY CHAFFEE videotape, writing, and copyediting for multimedia; TABLE 3. Examples of Employment Opportunities creauve writing for health promotion; advanced data for Nurses in Health Communications presentation; writing and producing materials for patient education; ethics of authorship and editorship; and presenting with impact. AMWA offers a core curriculum certificate that is attained by completing required and elective courses at the annual conference and regional meetings. For the past 18 years, the American Medical Association has offered an annual Medical Communications and Health Reporting Con- ference. The 1998 program, "Immediate Impact: Communicating Medical and Health News in a World of Instant Updates," was designed for medical reporters, broadcasters, spokespeople, and communi- cations professionals. It featured workshops on broad- casting; scriptwriting; camera ease; speechwriting tech- niques; platform-speaking skills; understanding the media; relating effectively to the media; entertain- ment's role in health education, radio reporting, and programming; and communicating in a crisis. In addition to the workshops, individual coaching ses- sions were available for $125 to $150 (American Medical Association, 1998). Health communications internships may be inte- grated into nursing programs. The American Public Health Association (APHA, 1998) offers an internship in its Communications Department for undergradu- ate and graduate students desiring practical experience in the role of communications in advocacy and promoting public health. Activities include writing and editing news releases, writing and editing articles for The Nation's Health newsletter, fielding media inquiries, covering public health news events, and designing material for APHA's Web site. The International Academy of Nurse Editors (INANE) conducts an annual conference focused on issues in the world of publishing journals and newslet- ters in nursing. The 1999 conference, "Publishing in Nursing: Power, Passion and Participation," was held August 5-7, 1999, in Cairns, Australia. A number of traditional and electronic resources are available for nurses interested in health communica- tions and health writing (Table 2). Health Communications Employment Opportunities for Nurses A wide variety of employment opportunities exist for nurses with education and experience in communi- cations (Table 3). Depending on geographic area, positions may be available in communications, market- Position Employer Reporter and executwe editor Medicare Compliance Alert (a newsletter covering health care fraud and abuse) (Rockvllle, MD) Nurse or nurse educator PosEt~onIS to develop a penan- esthesla national pubhcatlon (UC Group, Rockvllle, MD) Health communication spe- IQ Solutions, Washington, DC c~ahst Communications manager George Washington University and pubhcatLons director Medical Center, Washington, DC Communications officer American Red Cross, National Capital Chapter, Wash- ington, DC Analyst and writer Oncology Roundtable (think tank that pubhshes 50 major reports, 1,200 presentations, and 25,000 research briefs annually) (Washington, DC) Reporter, national health beat United Communications Group (Rockvllle, MD) Commun~cattons assocLate International Center for Research on Women (Wash- ington, DC) Technical wrlter/pohcy analyst Aspen Systems Corporation, Health Dw~s~on, Ga~thers- burg, MD Communications speclahst Nonprofit agency dedicated to research on splntuahty and health Communications speclahst Macro International, Inc, Demographics and Health Research Dw~s~on, to assist with d~ssemlnatlon of popu- lation and health information in developing countries (Cal- verton, MD) Vice president, communica- Amencan Heart Association, tions Washington, DC Director of communications Hospice and Palhatwe Care of Metropohtan Washington, Inc (Washington, DC) Assistant editor Amencan D~abetes Assoc]a- tlon, Alexandria, VA Sen~or project manager Medical Med~a Associates, Madison, Wl, to develop pro- grams for k~dney dlalysts patients Medical writer/editor StrategLc Institute for Con- t~nu~ngHealth Care Educa- tion, Vienna, VA, to develop conhnu~ng educahon pro- grams for physicians, nurses, and pharmacists Medical writer Consumer Health Information Corporation, McLean, VA, to translate medical ~nformat~on ~nto language for consumers NOTE Poslt~ons were advertised in The Washington Post between June 1998 and May 1999, and the "American Medical Wnters Association Job Market Sheet," in April and May 1999 HEALTH COMMUNICATIONS EDUCATION ing, editing, writing, publishing, and other related areas. Recent advertisements sought writers, editors, media relations specialists, and communications spe- cialists for health-related ventures. These were most frequently located in classified employment listings under the terms "editor," "writer," "communications," and "publishing." AMWA (Table 2) publishes a Job Market Sheet that lists employment opportunities. Published bimonthly, it advertises positions for health writers, editors, project managers, managing editors, media specialists, and freelance writers. Media Initiatives The American Nurses Association (ANA) has initi- ated a program called "RN = Real News" to encour- age the media to use nurses as sources. One compo- nent of the strategy is the creation of a "media speaker" program. The program goal is to develop a group of registered nurses who agree to accept calls from journalists referred to them by the ANA Commu- nications Department. A data base has been created that lists more than 100 nurses available to provide information to the media. Sigma Theta Tau International has begun a public relations campaign designed to promote media cover- age of nursing research, raise awareness of the public, and position nursing as a first-line health information and knowledge resource. Nurses conducting research that has implications for consumers, supports trends in health care or relates to health issues, and concerns receiving public attention are invited to provide study data to Sigma Theta Tau International's Public Rela- tions Department ("Call for new research," 1998, p. 84). Conclusion One of the strategies proposed in the Woodhull Study on Nursing and the Media is to "Educate nurses in the use of effective public communication and media relations models" (1998, p. 13). Nursing programs have a tremendous opportunity available to educate nurses to become effective in health communi- cations. Innovative academic programs can prepare nurses to assume leadership roles in health communi- cations, to translate valuable information for public use, to develop media strategies, to effectively commu- nicate nursing's contribution to restoring and maintain- ing health, and to advocate effectively for public policy that affects health care. To overcome nursing's visibility problems, televi- sion journalist and producer Linda Ellerbee (personal communication, November 16, 1998) urges nurses to "Tell your stories." She encourages nurses to bring their stories to the media to highlight why nurses are the heroes of health care and to draw attention to the contributions made by nurses. Dr Eleanor Sullivan, President of Sigma Theta Tau International, stated recently, "The public must under- stand how we directly affect them. 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