Education for Genetics and Nursing Practice

AACN Clinical Issues Volume 13, Number 4, pp. 492-500 © 2002, AACN Education for Genetics and Nursing Practice Janet K. Williams, PhD, RN, CPNP, CGC, FAAN New human genetics discoveries are emerging from the Human Genome Project and privately funded genetic research programs. In the current phase of scientific discovery, a comprehensive human genome map is being completed, genes are being associated with specific diseases, relations between genetic characteristics and drug response are being identified, and potential new treatments are being explored. As genetic discoveries are made, they are announced quickly to the public with the expectation that they will lead to new and better options for promotion of health and prevention of disease. Despite the rapid pace of genetic discovery, scientific knowledge for the clinical application of new genetic discoveries is not yet fully developed. The state of knowledge currently is in a time lag between the moment when new genetic discoveries are made and the point at which scientific knowledge necessary for clinical applications has been developed.1 This time lag is apparent in both nursing practice and overall healthcare delivery. Nurses are challenged to integrate new genetic information into their nursing care. They must determine ■ Genetic factors influence the risk for disease, selection of treatments, and overall health of persons throughout the life span. Nurses in critical care practice participate in assessing genetic risks for disease, implementing treatments, educating people about genetic aspects of health and disease, supporting the client’s abilities to cope with the information, and assisting the individual and family to make health-related decisions involving genetic information. Opportunities for critical care nurses to become knowledgeable about genetic aspects of critical care nursing exist through academic courses, continuing education, and summer institutes. Recently, new guidelines for the genetic education of nurses have been developed. However, genetic education opportunities are not available to all nurses throughout the United States. Genetic nursing education programs based on guidelines for integration of genetic knowledge into professional nursing practice are needed. (KEYWORDS: nursing education, advanced practice nursing, genetic counseling, genetic testing) ▪▪▪▪▪▪▪▪▪▪ From the University of Iowa, Iowa City. Reprint requests to Janet K. Williams, PhD, RN, CPNP, CGC, FAAN, 338 Nursing Building, University of Iowa, Iowa City, IA 52242 (e-mail: janet-williams@ uiowa.edu). 492 Vol. 13, No. 4 November 2002 EDUCATION FOR GENETICS AND NURSING whether current nursing interventions are appropriate for people with specific genetic risks for disease and those who may be receiving new therapies based on genetic research. Nurses must become knowledgeable about genetics and its application to clinical practice so they can develop appropriate genetic nursing interventions for people requiring critical care nursing and help people use genetic discoveries in a positive way.  Nursing Skills and Genetic Healthcare The application of genetic concepts to nursing practice began in the 1970s with nurses who functioned as genetic clinic coordinators, providing genetic counseling to persons who had genetic conditions or were at risk for such disorders. Many of these nurses were nurse practitioners or had been educated as clinical nurse specialists. They applied their knowledge of patient care management to the new field of genetic nursing. Newborn metabolic screening programs and prenatal diagnostic clinics were some of the first places in which nurses practiced genetic nursing.2 Before the 1990s, most genetic healthcare services focused on the diagnosis and management of relatively uncommon conditions with specific patterns of inheritance. The discussion of genetic information often occurred in outpatient settings where recurrence risk, disease-related information, and health management decisions were discussed with individuals and their families. In the early 1990s, however, the mapping and cloning of the BRCA1 gene for familial breast cancer created the opportunity for genetic information to be used in identifying risk for a portion of the population with a family history of a common disease.3,4 The discovery of this gene made it possible to offer predictive genetic testing to individuals with a strong family history of breast or ovarian cancer, and to begin the investigation of potentially beneficial genebased therapies. The discovery of genetic factors associated with common diseases, such as cancer, has given rise to the need for nurses to use this information in their own  493 assessments and intervention decisions for patients undergoing medical care for more common diseases. One important development throughout nursing and other health professions has been the creation of standards that describe what skills healthcare providers are expected to have with regard to genetic information. Several documents have been issued that describe the outcomes of genetic education for nurses, showing how professional nurses should be able to apply knowledge of clinical genetics in their nursing practice. The International Society of Nurses in Genetics (ISONG) has developed a statement on the scope and standards of genetics clinical nursing practice that describes the incorporation of understanding of genetics into professional nursing practice at the basic and advanced levels.5 Regardless of their practice level, nurses should be able to participate in collecting and obtaining genetic history information, offer genetic information, and provide explanations of genetic resources; participate in the informed consent and informed decision-making process; participate in the management of patients who have conditions with a genetic component; and evaluate and monitor the impact of genetic conditions, testing, and treatments on the person and the family.5,6 The American Association of College of Nursing, also has included genetic knowledge as a basis for skills essential to the practice of nursing. In their statement describing essential standards for baccalaureate nursing education programs, this organization recognizes that “advances in genetic knowledge and interventions will have a major impact on the health status of individuals and populations.”7(p1) It also specifies that all professional nurses should be able to include a genetic history in an individual’s risk assessment. Not only are nursing organizations addressing this issue, but many healthcare professions also are recognizing the need to prepare their clinicians to use genetic discoveries in their areas of practice. In 1994, a statement by a committee of the Institute of Medicine predicted that nurses and other healthcare providers are likely to play a critical role in providing genetic services. The committee noted that education 494  WILLIAMS would be needed in the ethical, legal, and social issues surrounding genetic diagnosis, testing, and screening.8 The National Coalition for Health Professional Education in Genetics is an organization that represents approximately 100 health profession organizations including the American Association of Critical-Care Nurses.9 This organization has issued a statement that describes 44 specific genetics core competencies of knowledge, skills, and attitudes that are essential for healthcare professionals. Although these core competencies do not represent a comprehensive description of activities that professional nurses would be able to provide, they are a foundation upon which education programs for nurses can be built. These statements all reflect awareness by professional nursing and interdisciplinary health organizations that nursing is an essential component of genetic healthcare delivery, and that education in genetics will enrich nursing practice. Although guidelines from professional organizations and accrediting bodies identify the need for nurses to have education on genetic topics, the expectation for nurses to be knowledgeable regarding genetic content is not yet reflected in questions on licensing or most certification examinations. In a survey involving 42 state boards of nursing, only 10% reported that genetics was included in their requirements for education programs leading to registered nurse licensure.10 Opportunities for nurses to become educated about genetics through basic, graduate, and continuing education are available. However, these are not widespread, and many gaps exist in genetics education for nurses.  Basic Nursing Education The recognition that nurses must be knowledgeable in genetics as a basic foundational science is not new. Two nurse educators recommended 40 years ago that human genetics be placed in nursing curricula.11 This was echoed with a recommendation to require a human genetics course in basic nursing education.12 The ability to understand basic genetic concepts is critical for professional nurses who provide nursing care to patients whose AACN Clinical Issues illnesses have genetic components. Despite the logic of this statement, the inclusion of a human genetics course in nursing programs has been very slow, and only a few have made this important change. One obstacle has been the difficulty of making changes in prerequisite basic science courses in a curriculum. Another is the absence of faculty prepared to teach the clinical genetic content that builds on the basic human genetics concepts. One strategy for addressing the need for faculty to teach clinical genetics topics in nursing programs is the Genetics Program for Nursing Faculty at the Cincinnati Children’s Hospital Medical Center. Currently in its sixth year, this program has educated more than 150 faculty in registered nurse preparatory schools throughout the United States. Data from 60 faculty involved during the first 2 years of the program show how they applied the content in their own programs. The most common strategies were discussion of genetics with school administrators (92%) and faculty (88%). Most of the participants had added genetics content to their lectures (75%), and approximately one third (38%) were participating on curriculum committees in their institutions. The first Web-based Genetics Institute begins in 2002.13 Contact information for selected nursing genetic education resources is listed in Table 1. Basic components of genetics nursing education have been identified as essential for practicing nurses. At a National Institutes of Health meeting in 1995, 24 representatives of nursing specialty organizations, including the American Association of Critical-Care Nurses, expressed interest in educating their members about the implications of genetics for their practice.14 Through discussions with nursing organization representatives, a template for a core curriculum was developed. Ten themes of content were validated by 175 respondents from ISONG and the Oncology Nursing Society Genetics Specialty Interest Group.15 This core curriculum includes genetic topics essential for nurses in all areas of nursing practice (Table 2). Opportunities for integrating genetic content in existing nursing courses throughout undergraduate education were described by Lashley.16 Examples that may support the Vol. 13, No. 4 November 2002 EDUCATION FOR GENETICS AND NURSING  495 TABLE 1  Genetics Education Resources Genetics Program for Nursing Faculty Cynthia Prows, RN, MSN Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio 45229 cindy.prows@chmcc.org A Practice-b based Genetics Curriculum for Nurse Educators Dale Lea, RN, MPH, FAAN Foundation for Blood Research PO Box 190 Scarborough, ME 04070-0190 Betty Gallucci, RN, PhD University of Washington Biobehavioral Nursing and Health Systems Box 357266 Seattle, WA 98195-7266 Marcia Hern, EdD, RN University of Cincinnati College of Nursing 3110 Vine Street Cincinnati, OH 45221-0038 Marcia.hern@uc.edu dlea@fbr.org Genetics and Nurse Practitioner Program Genetics & Your Practice Sarah Sheets Cook, RNC, MEd March of Dimes PO Box 1657 Wilkes-Barre, PA 18703 Fax: 570-825-1987 Columbia University School of Nursing, Genetics Education for APN 630 W. 168th St., Box 6 New York, NY 10032 Advanced Practice Nurse in Genetics Credentialing Program 31 Center Drive, Room 5B-13 International Society of Nurses in Genetics, Inc. Bethesda, MD 20892-2718 Rita Black Monsen, DSN, MPH, RN sgi@mail.nih.gov NINR Summer Genetics Institute monsenr@ipa.net Post Doctoral Clinical Nursing Research Fellowship Genetics Advanced Practice Nurses Janet K. Williams, RN, PhD, FAAN International Society of Nurses in Genetics, Inc. 338 Nursing Building The University of Iowa Iowa City, IA 52242 Eileen Rawnsley, Executive Director 7 Haskins Rd. Hanover, NH 03755 Eileen.Rawnsley@valley.net Genetics Advanced Practice Nursing Masters or Post Masters Programs Janet K. Williams, RN, PhD, FAAN 338 Nursing Building The University of Iowa Iowa City, IA 52242 preparation of nurses for critical care include addressing genetic influences of diseases, issues surrounding genetic testing, genetic factors in communicable diseases, and pharmacogenetics topics. The nursing programs at the University of Iowa and Villanova University have used this model that integrates ge- netic content throughout the nursing core and elective courses.17 Curriculum materials also have been developed for nurse educators who wish to include specific concepts into undergraduate nursing education. The Practice-Based Genetics Curriculum for Nurse Educators in- 496  WILLIAMS TABLE 2  Genetic Content for Basic Nursing Education Indications for a genetic referral Basic human genetics Ethical and societal issues of genetics Appropriate genetic disorder, genetic healthcare, and support services resources Psychologic impact of genetics on the individual, family, and society Genetic evaluation and counseling Relevance of genetics to nursing practice New genetic methods for diagnosis and treatment Ethnocultural differences Own attitudes and values regarding genetic science and services Adapted with permission.15 cludes modules on prenatal topics, diagnoses of genetic conditions, and the Human Genome Project, as well as ethical, legal, and social issues related to application of genetic technologies to nursing practice.18 This curriculum is useful for nurse educators at the undergraduate and graduate levels. For acute care nurses, the modules on ethical, legal, and social issues in genetic testing, and those on late diagnosis and presymptomatic testing of genetic conditions may be especially pertinent. Additional materials are available through the March of Dimes. Although most of its materials are focused on maternal-child health nursing, the March of Dimes has produced a CD-ROM entitled Genetics and Your Practice, which provides content on genetic information, including adult-onset diseases.19 Nurse educators also may identify advanced nurse practitioners in genetics through ISONG who could provide guest lectures or contribute in other ways such as offering clinical experiences, identifying families who could speak to students on their experiences with genetic healthcare, or suggest resources on specific genetic nursing topics at the basic nursing level. Distance learning opportunities are being developed, and many are in the initial stages of production. A National Institutes of Health (NIH)-funded Web-based course on Family as Context for Clinical Genetics currently is being produced by a team headed by Dr Ca- AACN Clinical Issues role Kenner at the University of Illinois in Chicago. An interactive CD-ROM on ethics and genetic testing is being developed at The University of Iowa. Drs Janet Williams and M. Patricia Donahue are creating a CDROM that will include modules on ethics, genetic testing, and case studies, in which nurses can apply ethics and genetics principles in two clinical situations. This project is being funded by the Ethical, Legal and Social Issues research program of the National Human Genome Research Institute. Additional Web-based courses under development should be available within the next few years. Nurses who want to find continuing education opportunities can contact the executive director of ISONG to obtain the name of a genetic nurse in their area. These nurses may be able to identify continuing education lectures or programs on genetic topics of interest to nurses. Nurses in basic nursing degree programs who are interested in increasing their knowledge of genetic topics traditionally have negotiated genetic clinical experiences and independent study opportunities. These nurses have devised individualized plans of study that involved basic genetic science courses, electives, and clinical nursing experiences with patients who have genetic health problems. Many nursing students completing degrees in institutions that do not have formal genetic nursing courses will need to use this approach. This necessity is likely to continue until most nursing programs implement specific genetic content either throughout their curriculum or in focused genetic nursing courses.  Graduate Nursing Education Knowledge of clinical genetics topics is needed by advanced practice nurses who specialize in genetic nursing and those who are specialists in a specific area of nursing such as critical care.20,21 Two specialty nursing organizations have recognized the importance of genetic knowledge for their members, and these organizations have issued statements that describe expectations for nurses who assist their patients in using genetic information. These two organizations are the Association of Women’s Health, Vol. 13, No. 4 November 2002 EDUCATION FOR GENETICS AND NURSING Obstetric, and Neonatal Nurses (AWHONN) and the Oncology Nursing Society. The AWHONN statement emphasizes the importance of preparation for nurses who participate in the care of women and newborns undergoing or being considered for genetic testing and treatment.22 In 1998, the Oncology Nursing Society published statements on The Role of the Oncology Nurse in Cancer Genetic Counseling, and on Cancer Genetic Testing and Risk Assessment Counseling.23,24 The standards of practice for general oncology nurses, clinical specialist oncology nurses, and genetics oncology clinical specialists are the basis for education recommendations to be published next year.25 Whereas these two organizations have begun the process of defining what expert nurses need to know about genetics to apply this knowledge in their clinical practice, many other specialty organizations have not yet developed descriptions for application of genetic information in their specific area of nursing practice. Content that forms the foundation of genetic education in Master’s nursing education for advanced practice nurses is listed in Table 3. These topics are necessary for preparing advanced practice nurses to integrate genetic knowledge into their practice, regardless of their specialty. A clinical nurse specialist role in genetics was first described in the 1980s for nurses who provide genetic counseling and advanced practice nursing as members of medical genetics teams.26 These nurses work in a variety of settings such as medical genetics clinics, familial oncology diagnostic and treatment programs, and genetic disease management programs. A credential that recognizes advanced practice nurses in genetics was implemented by ISONG in 2001, including the education needed by nurses who apply for the advanced nurse practitioners in genetics (APNG[c]) credential. For the first 5 years of the credentialing program, nurses who wish to apply for this credential can acquire the necessary education through academic or continuing education.21 Several options for obtaining graduate academic and clinical courses in advanced practice genetic nursing are available. However, only a few programs have these  497 options, and at this time, each requires oncampus attendance, limiting the number of students who can attend these programs. Specific graduate programs at the University of Iowa and the University of Washington prepare nurses to be advanced practice nurses in genetics. Several graduate nursing programs, such as the University of Cincinnati, are exploring ways to offer post-Master’s certificates in advanced practice genetic nursing. These opportunities may be most appropriate for nurses with advanced practice skills in a specific specialty area who wish to increase their abilities to provide advanced practice genetic nursing in that area. Another genetics education option in Master’s nursing education involves integrating content into existing courses or adding courses for students who will become nurse practitioners or clinical nurse specialists in areas such as oncology. In one such program at Columbia University, students complete didactic and clinical courses that complement their advanced practice focus in one of the nurse practitioner programs. Several graduate schools, such as those at Emory University and Johns Hopkins University, also include genetic content in advanced practice courses. In addition to completing Master’s programs in preparation for advanced clinical practice, nurses also are pursuing education in genetics at the doctoral level to prepare themselves for careers in genetic nursing research and education. Although no formal doctoral programs in genetic nursing have yet been established, nurse scholars are developing their own programs of study that focus on genetic nursing research topics. The Summer Genetics Institute, offered by the National Institute of Nursing Research (NINR), is one education opportunity for predoctoral or postdoctoral nursing scholars who have an interest in genetic nursing research. This intensive training program is designed to prepare nurse scholars to engage in a formal program of study with classroom and laboratory components on genetics. One postdoctoral training program also has been funded by the NINR. The first NINRfunded postdoctoral fellowship training program was started at the University of Iowa in 2000. 498  WILLIAMS AACN Clinical Issues TABLE 3  Genetic Content for Master’s Nursing Education for Advanced Nursing Practice Genetic mechanisms influencing human health and illness Genetic and environmental factors involved in etiology of Mendelian disorders and genetically complex common disorders Family genetic history and physical assessment for Mendelian disorders and genetically complex common disorders Health risk implications of Mendelian disorders and genetically complex common disorders for family members Health promotion in persons and families with Mendelian disorders and genetically complex common disorders Individual, family, and societal responses to genetic information Integration of genetic healthcare into healthcare systems for individuals, families, and communities Relationships among culture, ethnicity, socioeconomic status, and demographic characteristics and use of genetic healthcare services Purposes, potential benefits, harms, and limitations of genetic tests for individuals, families, and society Ethical aspects of decisions regarding genetic tests and management options Management of disease and risk factors for Mendelian disorders and genetically complex common disorders Relationships between genetic characteristics and variable drug response in individuals Collaboration with genetic healthcare specialists and interdisciplinary healthcare providers  State of Education for Genetics and Nursing Practice Several important advances in genetic nursing have been made since Brantl and Esslinger urged nurse educators to “organize elementary human genetics as an integral part of the nursing curriculum.”11(p91) Some basic nursing education programs currently include genetic risk content in their assessment courses in response to the standards issued by the American Association of Colleges of Nursing. Faculty who have attended summer genetics training institutes are incorporating genetic content into their courses, and their nursing students are expected to be informed about genetic aspects of health and illness in a variety of acute, chronic, and community healthcare settings. Two textbooks on genetics and nursing have been published.6,27 Curriculum modules are available to support educators,18 and two intensive summer genetics institutes are available to prepare faculty and nurse researchers. Standards have been published for genetic nursing practice, and a credential is now available to recognize those who meet standards of the nursing profession with regard to advanced practice nursing in genetics. Standards for educational preparation have been written for clinical nurse specialists in oncology. Nurse researchers have begun to include genetic methods in their programs of research, such as Dr Martha Hill’s investigation into genetic aspects of hypertension and Dr Debra Schutte’s study on genetic aspects of Alzheimer disease.28,29 Despite these tremendous advances, opportunities for nurses to become informed about genetics are limited and accessible only to those who can physically attend classes and continuing education meetings. Education efforts also are limited by the relatively small proportion of faculty who are knowledgeable about genetic topics, and by the small number of expert nurse clinicians who can mentor undergraduate and graduate nursing students. Most, if not all, education opportunities are available through textbooks, articles, on-campus classes, or continuing education opportunities. Web-based instruction on genetic nursing is being developed.  Strategies for Future Genetic Nursing Education The profession of nursing has several challenges to meet in addressing the need for genetic education for nurses. Genetics is a ba- Vol. 13, No. 4 November 2002 EDUCATION FOR GENETICS AND NURSING sic science that is foundational to the understanding of inherited factors influencing health and illness. Nursing education in genetics will be more meaningful when all nurses complete a human genetics course as a part of their basic or advanced nursing education. The integration of genetic concepts throughout the nursing curriculum and courses that focus on specific populations or genetic health problems are needed in basic and advanced practice nursing programs. The guidelines for practice issued by the National Coalition for Health Professional Education in Genetics and the American Association of Colleges of Nursing, as well as the recommended guidelines for Master’s nursing genetic education (Table 3) provide templates for the development of this nursing content.7,9,14,15 To educate nurses in genetic topics that influence human responses to health and illness, the profession of nursing must consider several strategies. Standards of care from all professional nursing organizations and education opportunities are urgently needed to address genetic education needs of nurses who practice in a variety of settings and with specific populations. Endorsement of genetic knowledge has been articulated by several nursing organizations. However, standards for practice in genetic healthcare acute care nursing have yet to be developed. In addition, regulatory bodies must articulate what genetic competencies are expected at each level of nursing practice. Although some excellent instructional materials are available, these tend to focus on ethics, genetic testing, and the diagnostic and information-giving phases of genetic nursing. Little information is available yet to guide the practice of nurses who care for patients with complex chronic genetic illnesses or those in the acute phases of their diseases. One exception is a description of nursing care for patients with genetic disorders in an intensive care unit.30 Articles that highlight genetic topics of concern in perioperative nursing and gerontology nursing have been published, but much more is needed to provide a comprehensive basis for these aspects of nursing practice.31,32 Information on pharmacogenomics is becoming available,33,34 and advanced practice nurses will need to be prepared to incorpo-  499 rate discoveries of genetic aspects of individual drug responses into their clinical practice. Genetic information will continue to change with new discoveries in genetic science. It is imperative that nursing develop a body of knowledge to guide genetic nursing practice for individuals with acute nursing care needs and for people receiving nursing care, regardless of the healthcare setting.  Summary Nurses provide nursing care to individuals, families, and communities with diseases or at risk for diseases that have a genetic component. Such nursing care has evolved from the care of individuals with rare inherited conditions to the management of common conditions for which genetic components are being identified. Resources are emerging to support the integration of core genetic nursing content into all levels of nursing education. Standards for the application of genetic discoveries to clinical practice are needed for all aspects of advanced nursing practice. An organized and focused effort by nurse educators is needed to prepare nurses to apply genetic knowledge in professional nursing practice. References 1. Feetham SL. Overview of significance of genetics and health care: nursing and genetics, leadership for global health. International Council of Nurses Monograph. In press. 2. Williams JK. History of genetics and nursing. In: Report of the Expert Panel on Genetics and Nursing: Implications for Education and Practice. Bethesda, Md: US Dept of Health and Human Services, Health Resources and Services Administration, National Institutes of Health; 2002. 3. Hall J, Lee M, Newman B, et al. Linkage of early-onset familial breast cancer to chromosome 17q21. Science. 1990;250:1684-1689. 4. Miki Y, Swensen J, Shattuck-Eidens D, et al. A strong candidate for the breast and ovarian cancer susceptibility gene, BRCA1. Science. 1994;266:66-71. 5. International Society of Nurses in Genetics. Statement on the Scope and Standards of Genetics Clinical Nursing Practice. Washington, DC: American Nurses Association; 1998. 500  WILLIAMS 6. Lea DH, Jenkins, JF, Francomano CA. Genetics in Clinical Practice: New Directions for Nursing and Health Care. Sudbury, Mass: Jones & Bartlett; 1998. 7. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American Association of Colleges of Nursing; 1998. 8. Andrews LB, Fullarton JE, Holtzman NA, Motulsky AG. Assessing Genetic Risks: Implications for Health and Social Policy. Washington, DC: National Academy Press; 1994. 9. Core competencies in genetics essential for all health-care professionals. National Coalition for Health Professional Education in Genetics 2000 [online]. Available at: http://www. n c h p e g . o rg / n e w s - b o x / c o r e c o m p e t e n cies000.html. Accessed December 7, 2000. 10. Monsen R, Anderson G, New F, et al. Miles to go before we sleep. Nurs Health Care Perspect. 2000;21:34-37. 11. Brantl VM, Esslinger PN. Genetics implications for the nursing curriculum. Nurs Forum. 1962;1:91-100. 12. George JB. Genetics: challenges for nursing education. J Pediatr Nurs. 1992;7:5-8. 13. Prows CA, Latta KK, Hetteberg C, Williams JK, Kenner C, Monsen RB. Preparation of undergraduate nursing faculty to incorporate genetics content into curricula. Biol Res Nurs. 1999;1:108-112. 14. Jenkins J, Prows C, Dimond E, Monsen R, Williams J. Recommendations for educating nurses in genetics. J Prof Nurs. 2001;17:283290. 15. Jenkins J, Dimond E, Steinberg S. Preparing for the future through genetics nursing education. J Nurs Schol. 2001;33:191-195. 16. Lashley FR. Integrating genetics content in undergraduate nursing programs. Biol Res Nurs. 1999;1:113-118. 17. Zamerowski S, Lumley M, Arreola RA, Dukes K, Khan A, Sullivan L. The psychosocial impact on high-risk pregnant women of a noninvasive prenatal diagnostic test. Fetal Diagn Ther. 1999;14:125-126. 18. Lea DH, Thomas Lawson M. A practice-based genetics curriculum for nurse educators: an innovative approach to integrating human genetics into nursing curricula. J Nurs Educ. 2000;39(9):418-421. 19. March of Dimes. Genetics and Your Practice [CD-ROM]. 1999. Available at: www.modimes.org. Accessed August 2002. AACN Clinical Issues 20. Sparacino PSA. Genetic research: every nurse’s new frontier. Clin Nurse Specialist. 1997;11:194. 21. Credentialing Committee. Call for portfolios for the advanced practice nurse in genetics credential. Newsletter of the International Society of Nurses in Genetics. March 2001:1-14. 22. Association of Women’s Health, Obstetric, and Neonatal Nursing. Role of the registered nurse in support of patients as related to genetic testing. Available at: http://www.awhonn. org. Accessed: September 19, 2002. 23. Oncology Nursing Society. Cancer genetic testing and risk assessment counseling. Oncol Nurs Forum. 1998;25:464. 24. Oncology Nursing Society. The role of the oncology nurse in cancer genetic counseling. Oncol Nurs Forum. 1998;25:463. 25. Jenkins J, Masny A, Tranin A. Recommendations for Cancer Genetics Nursing Practice and Education. Pittsburgh, Pa: Oncology Nursing Society. In press. 26. Fibison W. The nursing role in the delivery of genetic services. Issues Health Care Women. 1983;4:1-15. 27. Lashley FR. Clinical Genetics in Nursing Practice. 2nd ed. New York, NY: Springer; 1998. 28. Hill MN. Comprehensive hypertension care in young urban black men: an example of a program of nursing research that integrates genetic science, clinical interventions, and patient outcomes. In: Olsen SJ, BaxendaleCox L, Mock V, eds. Clinical Genetics Nursing Clinics of North America. 2000;35:773-794. 29. Schutte DL. The Relationship of Genotype to Cognition, Function, and Behavior in Alzheimer Disease [doctoral dissertation]. Iowa City, Iowa: University of Iowa; 2001. 30. Schutte DL. Genetic illness in the adult ICU: implications for nursing practice. Crit Care Nurse. 1995;15:49-56. 31. Lea DH, Tinley S. Genetics in the OR implications for perioperative nursing practice. AORN J. 1998;67:1175-1191. 32. Schutte DL. Impact of Alzheimer disease genetics on advanced gerontological nursing practice. AACN Clin Issues. 1998;9:513-523. 33. Read CY. Pharmacogenomics: an evolving paradigm for drug therapy. MEDSURG Nurs J Adult Health. 2002;11:122-125. 34. Roses AD. Pharmacogenetics place in modern medical science and practice. Life Sci. 2002;70:1471-1480.