This paper describes the Adolescent Subspecialty Track in the Pediatric Nurse Practitioner Program at the Yale University School of Nursing (YSN) which prepares nurse practitioners at the Masters Degree level to provide primary care to adolescents.
It is generally acknowledged that the medical profession recognized the unique medical needs of adolescents, and the need to provide special services to members of this age group, when Dr. J. Roswell Gallagher established the first adolescent service at Boston Children's Hospital in the early 1950s. Since then the numbers of inpatient and outpatient medical services for adolescents have increased. However, educational programs in adolescent health care for members of the nursing and medical professions are a recent development that is occurring slowly. The complexity of the physical, physiological, and psychosocial changes that take place during adolescence create unique and multiple health needs for members of this age group. The increasing incidence of pregnancy, venereal diseases, and accidents seen annually in adolescents reinforces the need for specialized services. More physicians and nurses need to become knowledgeable and skilled in providing health care to adolescents. It is an opportune time for nurses to establish their roles as nurse practitioners in the area of adolescent health care in order to actively influence the provision of services to this age group
Roles and Responsibilities of the Nurse Practitioner
The roles and responsibilities assumed by the nurse practitioner who provides care to adolescents are dependent upon one's educational background, knowledge, capabilities and desires. Since the Pediatric Nurse Practitioner (PNP) program and the Adolescent Subspecialty Track at YSN focus upon preparing students to become primary care providers, that role will be emphasized in this paper.
As a primary care provider, the nurse practitioner engages adolescents in rlJTvcwl relationships with the objective of assessing, identifying, and managing the health needs of adolescents so an optimum level of health can be achieved and maintained. In accordance with the definition of a primary health care nurse practitioner by the American Nursess Associations Council of Primary Health Care Nurse Practitioners (ANA, 1980), the nurse practitioner coordinates and provides continuous and comprehensive health care which includes the assessment and management of both health and disease states. It is especially important to recognize the unique developmental needs of adolescents which are both physical and psychological, and the interplay of these needs with the social, cultural and economic environments of the adolescent and his family.
The development of sound and sensitive interviewing and counseling skills is of utmost importance for establishing and maintaining effective relationships with members of this age group. Awareness of one's own values, and the ability to separate such from those of the adolescent, enables the clinician to provide more objective counseling. Through the caretaking relationship, nurse practitioners should help adolescents learn to accept responsibility for their own health care and to become responsible and informed health care consumers. Prior to adolescence, this responsibility has usually been assumed by the parents. Both parents and adolescents will need support and guidance from the nurse practitioner in making this transition. Gradually the relationship between the practitioner and the adolescent develops to one where there is mutual goal setting concerning the health needs of the adolescent.
In the primary care setting the nurse practitioner needs to be able to assess whether the physical growth, sexual maturation, and psychosocial development of adolescents is progressing normally toward that characteristic of adulthood. One also needs to be able to assess and manage the common health needs of adolescents such as acne, scoliosis, obesity, contraception, pregnancy, vaginal infections, and functional pain, to name a few. It is wise to provide as comprehensive care as possible because adolescents not only find it difficult to switch caretakers and thus, often do not follow through with referrals, but referrals also incur added expenses.
REQUIRED COURSES FOR FIRST-YEAR PNP STUDENTS
REQUIRED COURSES FOR SECOND-YEAR PNP STUDENTS
COURSES IN ADOLESCENT SUBSPECIALTY TRACK
The knowledge and skills required for establishing and maintaining effective clinical relationships with adolescents can be acquired through a planned program of study within the framework of a curriculum preparing one to become a Pediatric Nurse Practitioner. Following is a description of how such is done at the Master's Degree level in the Pediatric Program at the Yale University School of Nursing.
During the first year of the two-year Pediatric Nurse Practitioner program, students are required to take courses (Figure 1) which provide them with the theoretical knowledge and clinical skills to assess the health status, provide well child care, and assess and manage acute illnesses of infants, children, and adolescents. They are also required to take two research courses which prepare them for formulating and conducting a clinical research study which fulfills the Master's theses requirements.
During the second year, students have only a few required courses (Figure 2), which allows them the opportunity to pursue study in areas of special interest. Available options that exist in forms of both structured and independent study include newborn health care, adolescent health care, primary care of children of all ages, and chronic illness. At the completion of the program the majority of graduates are not only qualified to practice as Pediatric Nurse Practitioners with special skills within a specific area in pediatrics, but they also possess abilities to become leaders, teachers, and researchers.
During the first semester of the first year, content concerning adolescents is integrated into the Pediatric Health Assessment (N630) and Seminar in Child Development I (N637a) courses (Figure 3). Content integrated into the Pediatric Health Assessment course includes: interviewing adolescents and gathering a data base, breast examination, and female genitalia examination. Time is allowed following the didactic portion of these classes for students to begin practicing these skills. Adolescent physical and psychosocial development is presented in three two-hour sessions in the Seminar in Child Development I course. The major physical and sexual changes which occur during the prepubertal and pubertal years are covered as well as content concerning adolescent psychosocial development including: cognitive development, body image, sexuality, personality, identity formation, independence, and peer and family relationships. Integration of this material during first semester courses enables students to become exposed to and to develop a foundation of knowledge concerning the complex physical and psychosocial changes of adolescence.
During the second semester of the first year all students are required to take the Caretaking Process in the Adolescence (N641). The clinical process is emphasized in this course so that students learn effective techniques for gathering histories, performing physical and pelvic examinations, and addressing and managing the common problems of adolescence. Theoretical content concerning the physical and psychological needs of teen-agers is integrated into the teaching of the clinical process. Case studies and bibliographies are provided prior to all sessions. Students actively participate in the class through discussion and role play.
All students are also required to take Clinical Practice in the Primary Care of Adolescents (N640). Students are expected to achieve beginning clinical skills in the assessment of the physical, sexual, and psychosocial development of adolescents, and in the assessment and management of common health needs of adolescents. All students have been required to spend four hours per week in the Adolescent Clinic at Yale-New Haven Hospital for 10 weeks. Supervision is provided by the nursing faculty with the ratio of faculty to students being 1:1 or 1:2. Medical back-up is provided by the physician who directs the clinic.
Students can pursue advanced clinical and academic study in adolescent health care during the second year of the program. Advanced Adolescent Seminar I (N839a) provides an opportunity for the student to explore issues in the adolescent health care in greater depth and broader perspective than that studied in the basic required course (N641). The seminar is designed to foster student independence and acceptance of responsibility for self-learning. The student has the opportunity to discuss various roles of the adolescent nurse practitioner, review and discuss available literature concerning issues in adolescent health care, gain an increased understanding of the assessment and management of complex physical and psychosocial health needs of adolescents, and gain an understanding of the importance of interdisciplinary collaboration for meeting the needs of the adolescents. Topics are selected by the students and have included: making the pelvic exam an educational experience, counseling issues concerning abortion in adolescents, counseling issues concerning the adolescent rape victim, homosexuality, motivating the adolescent to be an effective contraceptor, and juvenile delinquency. Requirements of the course include active participation in the seminars, leadership of at least one seminar, annotated bibliographies of at least three journal articles for each session, and a written self-evaluation at the end of the semester.
In the course, Advanced Adolescent Seminar II (N839b), students execute and complete a project such as writing an article for publication in a professional journal, writing an educational pamphlet for patients, or presenting a seminar or workshop about adolescents for a group of nurses or parents. The students also have the opportunity to acquaint themselves with local, state, and national resources which provide or influence adolescent health care by seeking out and visiting such resources. Engaging in this type of activity serves several purposes. First of all, the student has the opportunity to engage in professional activities of the adolescent nurse practitioner other than that of providing primary care; secondly, one has the opportunity to plan and develop a project independently and creatively; and thirdly, the student has the opportunity to disseminate information about the work of a pediatric nurse practitioner in the field of adolescent health care. It is hoped that this opportunity will serve as a stimulus for students to pursue this type of activity throughout their professional careers.
Clinical experiences (N840a & b) offered on the advanced level consist of either providing primary health care to adolescents or teaching parenting classes at one of the local high schools. This advanced primary care experience enables students to further develop their skills in: engaging adolescents in caretaking relationships, refining one's interviewing techniques, assessing and managing common and complex physical and psychosocial health needs of adolescents, developing further ability to integrate theoretical knowledge about adolescent growth and development to the health needs of adolescents, and in delineating one's role as an adolescent nurse practitioner. Teaching parenting classes in one of the local high schools enables students to: further understand the needs of adolescent parents, prepare and conduct parenting classes for student parents, and integrate adolescent developmental theory into class content and teaching strategies.
All courses on both beginning and advanced levels of the adolescent component of the program are taught utilizing an adolescent developmental framework. The uniqueness and complexity of the physical and psychological changes which occur during adolescence form the basis for the health care needs of members of this age group Concepts of the nursing process are used when teaching students to assess and manage the health needs of adolescents.
Evaluation occurs as an ongoing process, between students and faculty. Both formal and informal means are used for the evaluation of clinical and academic experiences in the Adolescent Subspecialty Track. At the end of the semester, students complete evaluation forms regarding the content of the courses and the quality of the clinical experiences. Students' comments are taken into account when revisions are made. Students also complete self-evaluations based on their perceptions of their abilities to meet the objectives of beginning and advanced clinical experiences and of advanced seminars. Faculty write formal evaluations concerning students' performances and abilities to meet the objectives of clinical and academic courses at the end of each semester. Faculty meet with students individually to discuss the students' selfevaluation and the faculty's evaluation of the students' performances in the clinical area twice a semester. Faculty determine final grades for clinical and academic courses. Informally, faculty and students frequently discuss courses and clinical experiences and the students' progress through such meetings. If appropriate, changes are made as problems arise.
Goals for the Future
The ultimate goal of Yale School of Nursing's Adolescent Subspecialty Track is to prepare nurse practitioners to provide high quality primary care to adolescents, and to become advocates of such services for this age group It is essential for all clinicians who care for adolescents in all settings to acquire the knowledge and skills needed for establishing effective clinical relationships with adolescents. One does not have to be a speciahst in adolescent health care to care for adolescents, but certain skills are needed to be effective with members of this age group It is hoped that programs preparing all types of nurse practitioners integrate content concerning adolescents into their curricula.
On a smaller scale, goals within the program include the following: locating and developing more clinical sites for students to obtain experience in providing primary care and teaching parenting classes to adolescents; further development of theoretical content concerning the care of adolescent males, especially adolescent fathers; development of audiovisual aids for students concerning adolescent health care; and the development of research tools for evaluating job opportunities and the role of the nurse practitioner in adolescent health care.
In light of the limitation of available health care services for adolescents and of the small numbers of personnel to provide those services, it seems an opportune time for nurse practitioners to develop their role in adolescent health care. This paper describes the curriculum of the Adolescent Subspecialty Track which is a part of the Pediatric Nurse Practitioner program at the Yale University School of Nursing. One who graduates from the PNP program with a specialty in adolescent health care is able to practice as a PNP with an emphasis upon providing primary care to adolescents, to conduct clinical research, and to begin functioning as a leader in the profession. It is hoped that more nursing schools develop curricula for preparing nurse practitioners in the area of adolescent health care.
- American Nurses' Association. (1980). The primary health care nurse practitioner (Pub. No. NP-61 5M 5/80). Kansas City. MO: author.
REQUIRED COURSES FOR FIRST-YEAR PNP STUDENTS
REQUIRED COURSES FOR SECOND-YEAR PNP STUDENTS
COURSES IN ADOLESCENT SUBSPECIALTY TRACK