Health education is an important professional function of nursing. Nevertheless, practicing nurses do not fulfill, nor do they feel comfortable fulfilling, this role of health education (Bullough, 1981; Caldera et al., 1980; Sutherland, 1980; Syred, 1981). Research has found that nurses perceive themselves as inadequately prepared to provide health education (Murdaugh, 1980; Parker, Alkhateeb, & Farkash Rosen, 1983; Phillips & Hekelman, 1983) and that nursing administrators perceive graduates at a lower competency level than do nursing educators (Stull & Katz, 1986).
Nursing education has the initial responsibility for preparing nurses to enter the profession as health educators. Yet, research has documented that health education content is not readily identifiable in baccalaureate curricula (Ackerman, Partridge, & Kalmer, 1981; Gleit & Graham, 1984). In integrated baccalaureate curricula, it is difficult to identify where health education content is presented or to see how health education is implemented in the various clinical experiences. No research was found that studied perceptions of baccalaureate students and their faculty regarding the students' preparation or ability in the health educator role.
The present study explored both student and faculty perceptions about health education competence. Attitudes regarding present and desired competence levels were compared for faculty and students from two baccalaureate nursing programs. In addition, relationships between descriptive profile and competence were examined.
The nurse's role as a health educator is accepted as a professional responsibility of graduates of baccalaureate programs. Various nursing groups have identified the minimal competencies of new graduates to include the use of the teaching process with individuals and groups.
A National League for Nursing (NLN) task force on competencies of graduates of nursing programs (1979) delineated competencies for the baccalaureate graduate to include teaching. Some of the desired competencies were:
* the assessment of learning needs of individuals, families, and groups;
* the ability to develop, implement, and assist other nurses with the teaching plan;
* the development and utilization of teaching strategies and aids;
* the initiation of both formal and informal teaching; and
* the evaluation of the learning of the individual, family, or group.
The Midwest Alliance in Nursing (MAIN) task force on entry-level competencies of baccalaureate graduates reached consensus on teaching and collaboration (Stull, 1986), finding that new graduates should need only minimal guidance to be efficient in: (1) assessing health care learning needs of patients, families, and groups; (2) working collaboratively with resource persons to develop teaching plans that incorporate individualized learning needs; (3) implementing and modifying teaching plans as indicated; and (4) evaluating and documenting outcomes of teaching plans (Stull).
The American Association of Colleges of Nursing (AACN) in their Essentials of Colleges and University Education for Professional Nursing (1986) identified the knowledge and clinical judgment skills necessary for defining learning needs and for educating individuals and small groups. In addition, the AACN document provided a rating scale, according to degree of supervision required, for clinical skills. In the area of health education, the expected teaching skills for graduates are rated as:
* beginning (with supervision) - demonstration and roleplaying;
* intermediate (limited supervision) - provision of health teaching, facilitation of group process, use of contracting and discussion, use of collaboration, coordination, negotiation, observation, and organization, and the measurement of health outcomes; and
* proficient (without supervision) - communication and recording health data.
Although health education is a professional expectation, the role of nursing education in this development is unclear. Two studies question the overt inclusion of health education content in baccalaureate programs. Ackerman, Partridge, and Kahner (1982), from a survey of NLNaccredited programs, concluded that programs were devoting minimal attention to health education content. They found that only 22% of the schools responding showed evidence of course content related te health education and that sequencing of learning was absent.
A similar study was conducted by Gleit and Graham ( 1984) to determine the patient-teaching content for the role of health educator and the types of assigned readings used in baccalaureate programs. Less than half of the schools that responded required readings covering the role and function of nurses as health educators. Although two thirds of the schools said that they incorporated content regarding the teaching role of the nurse, the content focused on the specifics of what to teach, not on the process of teaching.
The outcome competence of graduates of educational programs has been evaluated from various perspectives. The students' perception of their preparedness was addressed by AACN in the Generic Baccalaureate Nursing Data Project (Cassells, Redman, & Jackson, 1986a, 1986b). At graduation, 80% of the students believed that they were prepared in patient-teaching skills. In another study, educators and nursing service administrators from hospital, community, and skilled facilities rated the ideal and real functioning levels of new graduates of baccalaureate programs (Stull & Katz, 1986). For teaching skills, the educators rated graduates significantly higher than did the administrators; the educators rated new graduates at the "safe but practice needed" level while administrators rated the graduates at "supervision required" level. For ideal expectation of new graduates, all groups perceived that new graduates should perform at a higher level than they currently possessed. In fact, the administrators' ideal expectation, or desired competence, was the same as the level of real or current functioning perceived by the educators.
It is unknown whether students and faculty have similar perceptions of present levels of teaching skills and of desired levels. Also, most research done in this area has evaluated teaching skills as a composite whole. No study has focused on expectations for the subcomponent skills of health education.
The present study examined both student and faculty perceptions about health education competence. Specific research questions were:
1. Is there a difference in perception between student and faculty groups regarding present competence for health teaching and desired competence?
2. Is there a difference between present and desired competence within student and faculty groups?
3. Are there differences in student and faculty expectations regarding subcomponent skills of the health educator role?
4. Is there a relationship between the descriptive profile of subjects and their perception of present competence for health teaching and desired competence?
Subjects for this study were faculty and students in the final nursing semester of a four-year baccalaureate program from two midwestern institutions, a private college and a public university. The participation rate for the faculty was 94% (15 of 16) for the public and 91% ( 10 of 11) for the private institution. Fifty-five (50%) public- and 44 (90%) private-institution students completed a questionnaire.
The survey instrument for data collection was an investigator-developed questionnaire that included a teaching skills inventory and informational profile. The teaching skills inventory consisted of 41 specific items in the following areas: use of teaching process (14 items), content areas of education (four items), use of teaching strategies/ approaches (13 items), activities of the health educator (five items), and locations in which a nurse might teach (five items).
A five-point scale was used to rate each teaching skill on two dimensions: perception of present competence, and desired competence. Present competence was the perception of the skill currently possessed by the students; desired competence was the minimal skill level a graduate of a baccalaureate program should possess. The points on the scale included:
1. Complete mastery - able to perform competently and efficiently without supervision;
2. Competent - able to perform without supervision with reasonable efficiency;
3. Safe but practice needed - able to perform without supervision but more practice is needed in order to perform efficiently;
4. Supervision needed - understands the theory and principles but would need supervision because of !united practice or experience;
5. Supervision and instruction needed - was not introduced to the theory and principles and would need both instruction and supervision to perform the skill;
6. Not nursing - does not think this skill or activity should be considered part of the nurse's role.
The points on the scale and the definitions were derived from a scale developed by Benner and Benner (1979) to study skill level competence.
An informational profile was collected from student and faculty subjects. Information from students included age, grade point average (GPA), and value placed on health education as a part of the professional nurse's role. Faculty were asked questions regarding educational background and teaching experience (total length of time taught, length of time taught at baccalaureate level, and length of time taught at senior level).
Content validity of the questionnaire was established through literature and expert review. The instrument was pilot-tested for clarity. Coefficient alpha internal consistency reliability exceeded .92 for each group on both the present and desired competence.
After obtaining permission from the institutions and human rights approval, eligible students and faculty were contacted. Students were approached at the end of a regularly scheduled nursing class. Student volunteers completed the questionnaire. Faculty were surveyed via department mail. Students were asked to rate themselves as individuals; faculty were instructed to rate students as a group. The questionnaire took about 15 minutes to complete.
Overall and individual differences and relationships among and between the four groups were analyzed. This analysis involved: (1) subjects: informational profile and overview of responses of subjects by group, (2) overall effect: testing the overall effect of the present and desired competencies (MANOVA), (3) group differences: testing the differences between groups on each of the competency variables and testing the difference between the two competency variables for the groups (ANOVA), (4) individual item differences: testing of differences between groups on individual items of each dependent variable, and (5) relationships: examining relationships between informational variables and dependent variables (correlation and chi square). A level of .05 was established for significance.
Informational Profile of Subjects
Means for Faculty and Student Responses on Competence Levels to Use Teaching Process for Health Education
A total of 25 faculty from the selected private and public institutions completed the questionnaire (Table 1). The faculty were very homogeneous. They were experienced educators with master's degrees. Likewise, the 99 students who completed the questionnaire were very similar in age (young), GPA (B average), and the value they placed on the health educator role (very high).
The subjects overwhelmingly expressed the belief that the items on the teaching skills inventory (Table 2) were considered a part of the nurse's role. Only 12 subjects rated 15 items on the present competence dimension and 10 items on the desired competence dimension as not a nursing function. The 12 subjects selected from one to seven items as nonnursing functions. Since no patterns emerged indicating that any one skill was not considered a nursing function, the nonnursing option was deleted for data analysis. The mean response for the item was substituted in all data analysis in order to neutralize the effect on the total and individual item score.
The multiple analysis of variance (MANOVA) revealed a significant (F = 4.28; p = .0004) difference (Table 2). Students and faculty from public and private institutions differed significantly in their perceptions regarding present and desired competencies for health education.
An ANOVA examination of each dependent variable revealed significant difference among the groups on the present (F- 4.21;p = .0072) and desired (F=4.96;p = .0028) competence total score (Table 2). The greatest difference in present performance was between faculty (mean =119. 6) and students (mean = 97. 5) in the public institution. In desired performance, the greatest difference was between faculty from the public institution (mean = 99.9) and students in the private (mean = 70.5) and public (mean = 79.9) institutions.
Means for Responses Related to Specific Health Education, Teaching Approaches, Activities and Location
Comparing the differences between present and desired competence scores revealed a significant result (F = 3.92; p = .0104) between the groups. All groups defined desired competence at a higher level of performance than the
current students possessed. The students from the private institution had the greatest overall expectation regarding desired performance and the greatest difference between present and desired performance (mean difference = 34. 5). The perception of students from the public institution between the present and desired performance was narrow (mean difference = 17. 7) and was similar to the faculty from the public (mean difference = 19.7) and private (mean difference = 18.8) institutions.
When the perceptions of faculty members from private and public institutions were compared, similar patterns of performance emerged for both observed and desired student behaviors. The mean faculty perception inferred that the students as a group were currently able to perform health education without supervision but needed more practice to be efficient. The faculty believed that the students should be more competent and efficient in their performance at the end of their educational program than they are currently. The students from both institutions also had similar perceptions of their current and desired abilities. The students perceived that currently they could perform the skill without supervision and with reasonable efficiency. They expected, however, that their performance should be at a higher level.
Individual Item Differences
When individual items of the present and desired competence scales were examined, six trends emerged (Tables 2 & 3). First, the facility from the public institution consistently rated the students less competent than the other groups on all items. This faculty group perceived that their students were currently less capable and were expected to perform at a lower level than perceived by the other groups.
Second, all groups on all items perceived the current competence as equal to or less than the desired competence. The greatest change in performance expectation occurred for the categories of use of teaching approaches and activities of health educator. The current performance level was perceived at the "safe but practice needed" level. The desired performance in these categories was at the competent level.
Third, the students consistently had a higher expectation of their desired performance than the faculty. As a group, the students believed that their ability should be at the competent or better level. The exceptions were in the area of use of teaching approaches and aids and activities of the health educator. The students did not feel as confident about the use of lecture or computers and development or evaluation of health programs.
Fourth, the application of the teaching process with groups was consistently rated at a lower level than with individuals. When the means for the four individual and group items of teaching process were compared, the difference in performance was greatest for the present competence area. In desired competence, the expectation for performance with individuals and groups approached the same level.
Fifth, the students currently perceived themselves at the level that faculty perceived as desirable at the end of the educational program. The mean student perception of current performance (2.46) and the mean faculty perception of desired performance (2.32) were defined to be at the competent level.
Last, the desired competence at the end of the educational program for all groups was at the competent level - able to perform without supervision and with reasonable efficiency. This level was especially evident in the use of teaching approaches, use of simple teaching strategies and aids, and functions that occur in hospitals.
For faculty, no significant relationships emerged between the present and desired competence level and their educational preparation or length of time teaching (total, baccalaureate, and seniors). For students, a positive relationship was noted between both the present (r= .25; p = .015) and desired (r=.21; p = .041) competence score and value placed on role of health educator. The current and desired competence level did not vary by age or GPA.
The results of this study found faculty and student beliefs aligned with the recommendations of various professional organizations: NLN, MAIN, and AACN. Both students and faculty believe that graduates of a professional nursing program should be competent (able to perform with reasonable efficiency without supervision) to provide health education. Regarding the specific skills delineated by AACN, the expectation of both faculty and students in this study exceeded the recommendations. Faculty and students in this study indicated that the minimal or desired competence for the collaborator, coordinator, and evaluator roles of health educator was at the competent level; AACN recommended the intermediate level with limited supervision.
Currently, students and faculty do not perceive that the standards for desired competence are being achieved. In all areas, the present performance level was lower than the desired competence level. The discrepancy was least for the areas relating to use of nursing process, to use of simple aids, and to carrying out teaching functions that occur in the hospital or with individuals. These areas and functions traditionally receive emphasis in baccalaureate programs. Distinctive differences were noted between present and desired performance for use of nursing process with individuals and groups. Students and faculty currently perceive less competence in teaching of groups; however, the desired competence level for application of the nursing process with individuals and groups was similar. This difference between the application of the nursing process with groups and with individuals and between present and desired competence levels has implications for curriculum implementation. Changes in curriculum to emphasize the teaching of groups may need to occur if the professional recommendations of NLN, MAIN, and AACN are to be realized.
The evaluation of current and desired performance competency varied between students and faculty. Students consistently identified a higher level of performance than did the faculty. In fact, students currently perceived themselves at a level that faculty desires for graduates of a baccalaureate program. The students may have overrated themselves because they have not yet learned to evaluate themselves or because they were evaluating themselves as individuals, whereas the faculty evaluated the students as a group. Thus, impressions by faculty are a composite of all students at this level in a program, rather than an evaluation of an individual student.
The faculty's evaluations of present and desired competencies are similar to results reported by Stull and Katz (1986). Educators evaluate students at the "safe but practice needed" level and expect students to be at a more competent level. Nursing administrators from hospitals, community, or skilled settings in the Stull and Katz study did not share the competency rating of the educators. In fact, the relationship between faculty and student perceptions in the present study was similar to the difference for administrators and educators in the Stull and Katz study, i.e., the administrators rated the graduates at a lower competency level (supervision and practice required) than the educators (safe but practice needed), and the administrators' ideal functioning level was equal to the educators' actual performance level. Thus, students rated themselves at the same level that faculty identify as the desired level of competence, and faculty rated graduates at the same level that administrators in the Stull and Katz study desire for competency. These results indicate that students, faculty, and administrators are not satisfied with the current level of functioning, but that they disagree on desired functioning levels. Mutual examination of expected competence for graduates by educators and by administrators may resolve disparate views.
The findings of this study support previous research on the importance of health education and use of teaching approaches and aids (Caldera et al., 1980; Sutherland, 1980). The vast majority of students assigned a high value to health education as a role for professional nursing. Students responded favorably and with confidence to teaching strategies with which they are most comfortable. Access and familiarity with still visuale during the educational programs enhanced competency level and expectation. The students were less confident for demonstrations and discussions. These two teaching/learning methodologies were identified by Sutherland (1980) as being the most appropriate for nurses in patient education. Also, although students felt unskilled in the use of lecture and computers, they desired to be competent in these approaches.
Competency in health education is an expectation of professional nurses. Continued dialogue between service and education is required to establish mutual expectations for graduates. This dialogue provides answers to three questions:
* What proficiency levels and strategies for teaching can be expected for the graduate with the first professional degree?
* What growth in the health educator role should be expected from experience and practice in a service position?
* What role does advanced education play in the fostering of competence for the health educator?
When these levels of expectation are delineated, dialogue with students about reasonable expectation of their performance may reduce feelings of inadequacy about their preparation for the role of health educator.
- Ackerman, A.M., Partridge, K.B., & Kalmer, H. (1981). Effective integration of health education into baccalaureate nursing curriculum. Journal of Nursing Education, 20(2), 37-43.
- Ackerman, A.M., Partridge, K.B., & Kalmer, H. (1982). Health education in baccalaureate nursing curriculum: Myth or reality? Journal of Nursing Education, 21( 1), 15-22.
- American Association of Colleges of Nursing (1986). Essentials of college and university education for professional nursing: Final report. Washington, DC: Author.
- Benner, P., & Benner, R.V. (1979). The new nurse's work entry: A troubled sponsorship. New York: Tiresias Press.
- Bullough, B. (1981). Nurses as teachers and support persons for breast cancer patients. Cancer Nursing, 4, 221-225.
- Caldera, K., Colangelo, R., DiBlasi, M., Gorman, D., Kowalczyk, S., Mason, S., Murphy, M., Olson, A., Orr, C., & Ouellette, F. (1980). Exploration of the effect of educational level on the nurse's attitude toward discharge teaching. Journal of Nursing Education, 19, 24-32.
- Cassells, J.M., Redman, B. K., & Jackson, S.S. (1986a). Generic baccalaureate nursing student satisfaction regarding professional and personal development prior to graduation and one year post graduation. Journal of Professional Nursing, 2, 114-127.
- Cassells, J.M., Redman, B.K., & Jackson, S.S. (1986b). Student choice of baccalaureate nursing programs, their perceived level of growth and development, career plans, and transition into practice: A replication. Journal of Professional Nursing, 2, 186-196.
- Gleit, C.J., & Graham, B.A. ( 1984). Reading materials used in the preparation of nurses for the teaching role. Patient Education and Counseling, 6, 25-28.
- Murdaugh, C. L. (1980). Effects on nurses' knowledge of teachinglearning principles on knowledge of coronary care unit patients. Heart and Lung, 9, 1073-1078.
- National League for Nursing Task Force ( 1979). Competencies of graduates of nursing programs (Publication No. 14-1905). New %rk: National League for Nursing.
- Parker, M.C., Alkhateeb, W.A., & Farkash Rosen, D.L. (1983). A nursing inservice curriculum for patient education. Nursing and Health Care, 4, 142-146.
- Phillips, J.A., & Hekelman, RP. (1983). The role of the nurse as a teacher: A position paper. Nephrology Nurse, 5(5), 42-46.
- Stull, M.K. (1986). Entry skills for BSNs. Nursing Outlook, 34, 138, 153.
- Stull, M. K., & Katz, B.M. (1986). Service and education: Similar perspectives of the performance of the new baccalaureate graduate. Journal of Professional Nursing, 2, 160-165.
- Sutherland, M.S. (1980). Education in the medical care setting: Perceptions of selected registered nurses. Health Education, 11, 25-27.
- Syred, M.E.J. (1981). The abdication of the role of health education by hospital nurses. Journal of Advanced Nursing, 6, 27-33.
Informational Profile of Subjects
Means for Faculty and Student Responses on Competence Levels to Use Teaching Process for Health Education
Means for Responses Related to Specific Health Education, Teaching Approaches, Activities and Location