The language of revolution is often used to describe the changes in the health care industry over the past decade. And, indeed, changes have occurred. Technological advances, a new way of paying for hospital care for the Medicare population, and innovative mechanisms for delivering care have revolutionized the industry. One of the more interesting changes has been the shift in focus from institution-based care to home- and communitybased care (Hegyvary, 1990). In many ways, health care is returning to its origins.
Even within the arena of home care, the changes have been substantial. Patients who are acutely ill now receive care at home (Taylor, 1985). Technology has brought many patients home who would have required hospitalization five years ago. Not only has there been a change in the type of patient receiving home care, but the care delivery environment has changed dramatically. New players are delivering care, reimbursement regulations have been tightened, and the incentives for care decisions have changed. More complex and diversified knowledge, both clinical and administrative, is now required to provide and manage care at home.
Educational programs have worked hard to keep up with the changes that have occurred in the delivery system and within the home care industry. Increasingly, schools of nursing are addressing sociopolitical issues, adding content about the economic dimensions of care to the curriculum, and focusing on community-based content both at the baccalaureate and the master's level. Areas of specialization are developing at the master's level that prepare students for advanced practice in home care settings (Cary, 1988). The first such program was funded by the DHHS Division of Nursing in 1983 at the University of Michigan; today, there are at least 19 of these programs in place, with many schools developing such specialty programs. There is also specialization within programs, some preparing home care administrators, others focusing on clinical specialty roles (Hackbarth & Androwich, 1989).
Review of the Literature
Several studies have been undertaken to determine the appropriate content for graduate level programs preparing home health administrators and/or clinical specialists. Hanchett and Chambers (1987) surveyed home health care agency administrators and staff members to determine areas of interest for a proposed expansion of a graduate program in community health nursing. They found that clinical specialization within home health care was the area of greatest interest for both administrators and staff members, followed by home health care administration.
Hackbarth and Androwich (1989) advocated organizational theory, fiscal management, human resource development, management information systems, and marketing as important concepts and content areas for management in a graduate program. In addition, they recommended the following concepts and content areas as significant for nursing and public health education: concept and theory development, nursing theories, theory from related disciplines, ethical and legal concepts, and health care policy and delivery systems.
Barkauskas and Blaha (1989) surveyed 98 National League for Nursing (NLN) accredited schools of nursing offering master's degrees in nursing and two schools of public health offering graduate programs in public health nursing. Using open-ended questions, they asked respondents to give their opinions about the most important content areas in home care graduate curricula. In descending order of importance, respondents identified management, community, care of individuals and families, the context of home health care, and concepts relevant to home care nursing as essential content in a home care curriculum.
Another effort undertaken to determine the essential content for master's programs with a home care specialization was the joint venture by the Division of Nursing and the Catholic University, which resulted in The Consensus Report (Cary, 1989). A panel of 14 experts including home care administrators, researchers, and educators identified 12 primary cluster areas of knowledge and skill recommended for home care administrators. The cluster areas identified were finance/fiscal, human resource development, legal/ethical, management information systems, marketing, nursing science, operations, organization/ management, policy, public health science, quality management, and research.
No studies, however, explored the possible differences between faculty and home health care personnel in their perceptions about curriculum content. The purpose of this study was to answer the following research questions:
1. What are the essential elements of a clinically and an administratively focused home health master's curriculum?
2. How is content prioritized for these two foci?
3. Do differences exist between agency personnel and faculty in perceptions of essential content?
In addition, this study expands what is known about graduate home health education programs by elaborating on the previously mentioned consensus report in four important ways. This study distinguishes between the content needed for administrative and clinical curricula, prioritizes the content for these two foci, represents the opinions and perceptions of 118 clinicians and educators, and compares the perceptions of clinicians and educators regarding essential content for a master's-level home health curriculum.
For this study, researchers selected a purposive sample of 100 personnel in home health agencies and 100 faculty who taught either home health or community health content. To obtain diversity, researchers included a national sample of nurses representing large and small agencies from rural and urban areas and faculty from schools offering graduate programs in home health or community health nursing. Of the 118 respondents, 57 were agency personnel and 61 were faculty, for a return rate of 59%.
Forty-two percent of the respondents were master'sprepared; 37% were doctorally prepared. The majority specialized in either community health or public health nursing (76%). The remainder represented specialization in medical-surgical nursing, maternal-child nursing, psychiatry-mental health nursing, or some combination of two specialties.
The predominant type of agency represented by home health personnel was the freestanding agency (63%), followed by hospital-based (23%), and community or health department agencies ( 12%). The majority of agencies (85%) were nonprofit.
As might be anticipated, many respondents had firsthand knowledge of master's-level home health education. More than half of the faculty (52%) and slightly less than half of the home health agency personnel (42%) were either involved or planned to be involved in master's-level home health education programs.
From a review of the literature, 15 content curriculum areas for master's-level home health education were identified (Figure). For each of these 15 areas, respondents were asked to identify whether the content was essential, not essential, or a prerequisite to entering a master's-level home health program, first for a clinical curriculum and then for an administrative curriculum. After the respondents determined whether the content area was essential, not essential, or a prerequisite, they prioritized, for each focus, how important the element was in that curriculum. From the 15 content areas, they ranked what they perceived to be the seven most important areas.
The seven elements most frequently identified as essential in a clinically focused curriculum were:
* home health concepts, including reimbursement regulations, documentation, and quality assurance (92%);
* care of the acutely ill (82%);
* care of the chronically ill (82%);
* epidemiology (74%);
* community health concepts, such as working with groups and family assessment (71%);
* nursing theory (66%); and
* teaching learning theory (61%).
The seven elements rated most essential for an administrative curriculum were:
* home health concepts (98%);
* financial management (98%);
* management principles, including personnel management, risk management, and strategic planning (98%);
* program development (90%);
* marketing (90%);
* organizational theory (84%); and
* epidemiology (85%).
The differences identified for the two curricula foci are depicted in Table 1.
Respondents also were given the opportunity to identify any other content areas that they thought were essential to master's-level home health education programs. The content areas cited for a clinically focused curriculum were research, policy, and geriatrics. For an administratively focused program, legal issues and computers were listed in addition to research, policy, and geriatrics.
There was considerable agreement between faculty and agency personnel in identification of essential curriculum elements. However, there was significant disagreement in two content areas: epidemiology and nursing theory. Faculty believed that these two areas were essential to both curricula, whereas agency personnel did not consider them to be essential to either (Table 2).
First-ranked items also reflected a disparity between clinical and administrative foci (Table 3). Home health and management principles were ranked as the two most important elements for administrative programs, while care of the acutely ill and community health concepts received the highest ratings for the clinical focus.
There were significant differences in how the two groups prioritized curriculum content areas. In a chisquare analysis of differences, only 9% of agency personnel said community health concepts (working with groups, family assessment, etc.) were a priority for administrative focus, whereas 36% of faculty said they were a priority (?2 =10.94, p<0.0004). For the clinical curriculum, only 33% of agency personnel said community health concepts were important, whereas 57% of faculty said they were important (?2 = 5.93, p<0.01).
Essential Content of Curricula by Focus
Essential Curricula Content: Areas of Disagreement
First-Ranked Curricula Elements by Focus
Another area of difference was in the identification of prerequisites for each focus. Respondents identified the following as prerequisites for an administrative focus: pathophysiology, physical assessment, and care of the chronically and acutely ill. For the clinical focus, physical assessment, human development theory, and pathophysiology were the three most frequently selected prerequisites.
Finally, data were examined for differences among the various educational groups, between profit and nonprofit agency groups, and among the clinical specialty groups. No statistically significant differences between any of these groups were detected.
In summary, faculty and agency personnel generally agreed in identifying and prioritizing elements of a home health curriculum. The major areas of disagreement between these two groups were epidemiology and nursing theory with faculty describing them as essential to both curricular foci and agency personnel not identifying them as essential to either. This is perplexing because anecdotal reports of agency directors indicate that knowledge of epidemiology is important for all nurses practicing in home care settings.
The results of this study are encouraging for two reasons. First, the curricular elements identified by these 118 respondents were remarkably similar to those identified by the consensus panel, a group of leaders in academic and clinical settings. This study offers support for the usefulness of consensus panels in determining essential curricular elements. Second, the disparity between the elements of administratively and clinically focused curricula affirm that no single program can do it all; to prepare nurses to be effective in this highly fluid and dynamic environment, specialization must be offered at the master's level.
Graduate programs in home health education are likely to increase and to become broader in scope. Educators and practitioners must jointly examine the curricula of these programs to ensure the timeliness and appropriateness of their content.
- Barkauskas, V., & Blaha, A. (1989). The development of graduate nursing education: A survey of home care programs. Caring, 8(2), 16-20.
- Cary, A. (Ed.). (1989). Strategies for a collaborative future: The consensus report. National Consensus Conference on the Educational Preparation of Home Care Administrators (DHHS Grant No. D23NU00447-05). Washington, DC: The Catholic University of America School of Nursing and Division of Nursing, Health Resources & Services Administration.
- Cary, A. (1988). Preparation for professional practice: What do we need? Nursing Clinics of North America, 23, 341-351.
- Hackbarth, D., & Androwich, I. (1989). Graduate nursing education for leadership in home care. Caring, 8(2), 6-11.
- Hanchett, E., & Chambers, B. (1987). The need for graduate education in community health nursing: A survey. Public Health Nursing, 4 1), 65-70.
- Hegyvary, S. (1990). Redefining community. Journal of Professional Nursing 6(1), 7.
- Taylor, M. (1985). The effects of DRGs on home health care. Nursing Outlook 33, 290-291.
Essential Content of Curricula by Focus
Essential Curricula Content: Areas of Disagreement
First-Ranked Curricula Elements by Focus