A three-year federally funded project tilted "A Multi-Faceted Program for Continuing Education in Nursing" has been completed at the University of Texas Health Science Center School of Nursing at San Antonio.* The primary purpose of this project was to provide continuing education for registered nurses who lived and worked in two predominately rural geographical sections of South Texas, known as Northern Alamo and Golden Crescent (Figure 1).
At the time the project was initiated in September 1974, in addition to geographical constraints, there were several other factors that were barriers to providing continuing education for nurses in South Texas. A survey of the registered nurses in the project areas revealed that work and family responsibilities prevented many nurses from attending traditional continuing education programs that were offered in the closest metropolitan areas (a distance of up to 150 miles). Also, the rapid expansion of knowledge in the health field was widening the gap between what nurses were actually practicing and what was considered desirable practice. Public consumers were thought to be uninformed about the contemporary role of nursing and its potential services in the delivery of health care. The project was designed to overcome many of these barriers through the use of new and innovative methods of providing continuing education for registered nurses and through use of programs to provide the public with information on the role of the nurse in health care delivery.
The project designed provided for a multi-faceted approach to providing continuing education for registered nurses and for providing the public with information on the role of the nurse through the accomplishment of four major goals:
1. To undertake the development and administration of a self-assessment inventory.
2. To promote the use of self-instructional materials.
3. To implement a regional continuing education plan through establishment of satellite centers for continuing education in nursing.
4. To undertake continuing education approaches to inform the community about nursing and current developments in health care delivery.
Assessment of Nursing Continuing Education Needs
Fundamental to activities associated with accomplishment of project goals was the assessment of the educational needs of the nurses in the project region. Multiple sources of data were utilized to identify these needs, including: 1) results of a survey of registered nurses in the project region, 2) demographic data from the State Board of Nurse Examiners, 3) evaluation data from project-sponsored activities, and 4) composite results of the nursing selfassessment inventory. Figure 2, A Model for Assessment of the Continuing Education Needs of Nurses, depicts the approach used for total assessment of the continuing education needs of nurses in the project region.
FIGURE 1: Greater South Texas region for continuing education in nursing.
Goal I: Development and Administration of a Nursing Self-Assessment Inventory
A self -assessment inventory which tests the knowledge and skills of registered nurses was developed as one component of the project. The self-assessment inventory is an individualized diagnostic test that is prepared using a computer-based bank of nursing items. The inventory permits nurses to identify the current status of their knowledge in specific areas of nursing and to use the results as one method for identifying areas for continuing education study.
The basic design of the self -assessment inventory reflects the premise that there is significant variation in individual nursing practice. A program was developed so that the computer selects test items for the individual nurse that are based on the characteristics of the nurse's practice. In order to ascertain the characteristics of the nurse's individual practice, each selfassessment inventory participant was asked to provide data necessary for the construction of an individual practice profile. The profile included information on the practice setting, major clinical areas, client age groups, and usual patient problems encountered by the nurse. The profile was used as the basis for actual construction of an individualized self-assessment inventory.
Since the three-year project period did not permit development of an item bank containing items that reflected the entire domain of nursing, the domain of the nursing practice tested during the project period reflected the characteristics of the practice of registered nurses in South Texas. These characteristics were identified primarily through analysis of the data from the survey of the nurse population, demographic data from the State Board of Nurse Examiners, and the results of individual nursing practice audits completed by the initial self-assessment inventory participants. Based on the results of this analysis, the initial items in the item bank for the self-assessment inventory consist primarily of medical-surgical content applied in the hospital setting.
During the three-year project period, 178, or 2Vi% of the total nurse population in South Texas, completed the self-assessment inventory. All participants evaluated the inventory and their comments were generally favorable. The major positive fea ture of the inventory that was identified was its ability to provide direction for continuing education activities. The primary weakness related to the deficiency of items for certain individual nurse practice profiles.
Goal II: Promotion of the Use of Self-Instructional Materials
Another major focus of the project was the provision of and promotion of the use of self -instructional materials. The assessment of learning needs of nurses in the project area had identified that nurses were interested in obtaining and using selfinstructional materials, but that time, distance, and lack of knowledge of available materials were barriers.
The project attempted to overcome barriers to the use of self-instructional materials by cataloguing locally available self-instructional materials, purchasing self-instructional materials in areas of continuing education need, and establishing learning centers in rural communities that were centrally located in the project area.
During the course of the project three learning centers were established in three communities. Distance to the centers for nurses living in the project area was no more than 20 miles. The learning centers were located in educational institutions (two in community colleges and one in a public school district facility): Each learning center consisted of a room containing a videocassette player and receiver, audiocassette players, individual study areas, and a storage area for self-instructional materials.
The learning centers were used by project area nurses through learning laboratory sessions. The learning laboratory sessions permitted nurses to acquire relevant nursing knowledge through the use of self-instructional materials. The presence of a project staff member skilled in principles of adult education enabled identification of the unique learning needs of each nurse as well as identification of the nurse's unique style of learning. The nurse was also introduced to the use of the hardware for audio-visual self-instructional materials, thus increasing the methods whereby self-directed learning could take place. Sessions were scheduled three days each month. Based on input from project area nurses, usually sessions were scheduled for mid-week from early afternoon through early evening.
A variety of self-instructional materials were available during each learning laboratory session. The materials were organized into self-instructional units. Each unit contained: 1) learning objectives, 2) a pretest, 3) a post-test, 4) relevant printed audio and/or audio-visual materials, and 5) additional references. The self-instructional units used locally available selfinstructional materials and project-purchased materials which had been catalogued under nursing content topic headings. Materials purchased during the project period were selected on the basis of locally deficient content areas and areas of need identified through the needs assessment of the project area nurses.
Continuing Education Accreditation and Recognition Points (CEARP) were granted by the Texas Nurses' Association for all study units completed during the learning laboratory sessions.
The learning laboratories conducted during the project period were the first local effort made to provide continuing education for nurses who learn best via nontraditional methods.
Goal III: Establishment of Satellite Centers for Continuing Education in Nursing
The original project proposal described the establishment of a regional plan for providing continuing education in nursing. This plan involved the establishment of satellite centers in outlying communities, formation of an advisory council of nurses in each satellite area and provision and evaluation of continuing education programs in the area. Two satellite centers were established in the project region. The satellite centers were characterized by an advisory council consisting of nurses representing all nurses living and working in the area served by the satellite center. Each satellite center established during the project represented approximately 360 RNs in a five- to seven-county area. The advisory councils provided ongoing assessment of the continuing education needs of nurses in the satellite region and functioned in the planning and implementation of continuing education programs that met the identified needs.
Initial formation of the advisory councils was accomplished through meetings of representative nurses from all health care institutions in the satellite region. At the initial organization meeting the participants elected members of the advisory councils to represent all major areas of nursing, e.g., school nursing, hospital nursing, nursing education, etc. The elected advisory council then selected their own officers. A project staff member served as a consultant to the advisory council.
The advisory councils in the satellite areas represented the use of a decentralized approach to continuing education. Advisory council members participated in assessment of the special learning needs of nurses in their area, identified local resources, and learned to plan and implement locally presented continuing education activities. By the end of the project period both advisory councils were able to: 1) write program objectives, 2) plan a program, 3) prepare a budget for a program, and 4) evaluate a program.
During the project period, a total of 19 nursing continuing education programs were presented in the satellite areas. These programs represented the top ten areas of continuing education need as determined through the needs assessment, especially the results from the survey of needs of local nurses and the input of advisory council members. The advisory council members became increasingly involved in the planning and implementation of the programs as the project proceeded, so that by the end of the project period they possessed the knowledge and skills to plan and implement programs.
The decentralized approach to continuing education as provided through the implementation of a regional plan through establishment of satellite centers enabled nurses to keep abreast of new developments in nursing in healthcare. It increased the knowledge and skills of nurses in the satellite areas. The number of nurses attending continuing education activities increased from 59% to 75%, presumably as a result of the use of local facilities for presenting programs and the active involvement of local nurses.
Goal IV: Informing the Public About Nursing and Current Developments in Health Care Delivery
A major factor in the delivery of health care is the public's perception of the system and its workers. The primary purpose of this goal was to inform the public of the changes in health care delivery and the new roles the nurse was assuming. It was postulated that an increase in public awareness of the role of the nurse would enable nurses to more readily incorporate the new knowledge and skills they were acquiring through the project-sponsored continuing education activities.
A variety of approaches were used to present the programs, including television and radio programs, newspaper articles, and programs before community groups such as parent-teacher associations and local medical societies. In addition to programs for the non-nurse public, it was also observed that many nurses were unaware of the current changes in health care delivery, therefore nurses were also a target group. An exhibit on nursing was also piaced in the South Texas Health Education Center.
The content of the programs focused on five themes:
1. "Nursing is a technical professional occupation which requires various levels of college-based education." One target group for programs with this theme were local high school counselors.
2. "Nursing is complementary to and interdependent with medicine. Nursing has some functions independent of medicine. Some nurses are health professional colleagues. " A series of newspaper articles on nurses in special roles, e.g., a nurse geneticist and a nurse practitioner in a migrant clinic, exemplified use of this theme.
3. "Nursing is committed to the care of the sick and also to the maintenance of health, promotion of health and prevention of illness. Nurses function as health educators, health counselors and referral agents." An example of use of this theme was the involvement of nurses in a lecture series on health in aging that was sponsored by the elderly in the community.
4. "Nursing is expanding its role in primary care." A program on nurse practitioners was presented to the local nurses association.
5. "Nursing is increasing its accountability to the public, its participation in decision making about health care delivery and its role as a consumer advocate." Several programs on patients' rights and the rote of the nurse were presented on local television and radio stations.
During the three years of the project significant efforts were made to undertake continuing education approaches to inform the public about nursing and current developments in health care delivery. Over two thousand persons were reached as a result of group presentations and the authence for the mass media presentations was projected to be in excess of one million. A telephone survey was used as one method of evaluating the effectiveness of project-sponsored programs and revealed that 39% of the randomly selected population sample recalled nursing-related presentations on television, radio, and the newspapers.
The three-year project, a Multi-Faceted Program for Continuing Education in Nursing, provided for development of multiple new and innovative approaches to providing continuing education for nurses. The major accomplishments of the project were:
1. The development and testing of a nursing self-assessment inventory.
2. The establishment of learning laboratories for nursing continuing education in rural communities with emphasis on use of self-instructional materials.
3. Participation in the implementation of a regional plan for continuing education in nursing.
4. The preparation of nurses in rural areas in the skills of planning and implementation of local nursing continuing education programs.
5. The development and implementation of strategies for exposing the public to new roles of nurses through the use of mass media.
The author wishes to acknowledge the contributions of the following project staff to the implementation of the total project as well as to selected sections of this article: Pamela M. Blankinship, R.N., M.S.N.; Linda S. Camin, R. N., M.S.N.; and Nancy Maebius, R.N., M.S.N.