The growth of home health care in recent years has been dramatic. According to the National Association for Home Care (NAHC), the number of home health agencies in this country increased approximately 20% between 1977 and 1983 (déla Cruz, Jacobs, & Wood, 1986). The number of home health agencies is expected to increase by 13% to 20% during the 1990s (Londen, 1983 as cited in déla Cruz et al.). This growth has been attributed to a variety of factors including: diagnosis-related groupings (DRGs), the rise in the elderly population with the accompanying increase in chronic illnesses, improved government and private third-party reimbursement policies, and advances in technology that have made it possible to adapt high-tech equipment for home care (déla Cruz et al.).
The increasing complexities in home health care require that home health services be planned, organized, and directed by a master's-prepared professional nurse (Standard 1, Standards of Home Health Care Nursing, [American Nurses Association, 1986]). However, many home health agencies are not led by a professional with an advanced degree. In a 1984 study of home health administrators/supervisors in California, déla Cruz et al. (1986) found that only 24% had master's degrees.
Nurses enter home health master's programs with varying degrees of home health experience. Some have extensive experience, whereas others have limited or no experience. Although a survey of 577 National League for Nursing (NLN)-accredited baccalaureate schools of nursing (BSN) by Burbach, Schumacher, Lindsay, and Conrad (1988) revealed that 73% of BSN programs now include home health content in their curricula, most of the nurses entering graduate programs today have received little or no instruction in home health nursing at the undergraduate level. Therefore, the preparation of specialized nurses for leadership in home health nursing at the master's level presents challenges for faculty in schools of nursing. How programs adapt their clinical practicums to the varying backgrounds of students influences not only learning but also the students' satisfaction with the programs. The purpose of this study was to examine how baccalaureate nurses with varying degrees of home health experience are integrated into graduate clinical practicums. Specifically, how does a practicum meet the learning needs of both the novice nurse and the experienced nurse?
Review of the Literature
A review of the literature revealed studies related to the need for home health at the master's level and the educational needs for nurses in home health (Anderson, 1989; Barkauskas & Blaha, 1989; Graham, 1989; Hackbarth & Androwich, 1989), but no publications spoke to the difficulties of arranging for clinical experiences for novice home health nurses or how to upgrade the skills of the experienced nurse. Therefore, a survey of 10 graduate programs offering a master's degree in home health nursing was conducted to determine how the special needs of novice and experienced nurses are met within the clinical practicum.
This was an exploratory descriptive study. Ten home health nursing graduate programs funded by the Division of Nursing, Department of Health and Human Services (as of December 1988) were surveyed. These schools represented different regions of the continental United States (five from the eastern region, three from the central region., two from the western region).
The program representatives identified by the Division of Nursing were sent a letter explaining the study and notifying them that they would be contacted within two weeks to participate in the study. A graduate research assistant called and interviewed the representative or other designated faculty member who was most familiar with the graduate home health nursing courses. Although scheduling appointments for phone interviews was difficult in some cases, questionnaires were completed with representatives from all 10 programs.
The instrument used for data collection was developed by the researchers and consisted of six items to collect demographic information about the program and four questions regarding their clinical practicums. Two items were open-ended questions: (1) How do you adapt your clinical practicums for students who have no experience in home health nursing? and (2) How do you build on the skills of the experienced nurse in home health nursing? The questionnaire ended with a request for participants to describe anything else that adapted their clinical practicums to the special needs of their students; a sample of the curriculum guide or brochure also was requested.
All of the questionnaires were administered by the same graduate assistant in order to protect reliability as much as possible. Responses to the open-ended questions were coded and interrater reliability was established among the researchers. Frequencies were calculated for all responses.
All of the programs offered a Master's of Science in Nursing (MSN) with a specialty focus in home health nursing. Five programs offered a focus in administration or management, and three offered a clinical specialist focus. The number of required course credits for the programs varied from 35 to 45 semester credits; a 36-credit requirement appeared most frequently. The number of credits devoted to clinical practicums varied from a high of 12 credits to a low of three; a nine-credit requirement was reported most frequently. The greatest degree of consistency between programs occurred in the ratio of clinical hours to semester credits, with eight programs reporting a ratio of one credit to three hours of clinical practice. Although half of the programs had clinical practicums throughout the program, others demonstrated variability in clinical placement.
Adapting Clinical Practicums for Students
The questionnaire began by asking if the program required entering students to have previous experience in home health nursing. Only one program reported the requirement for previous experience. Two programs have recommendations for previous experience but admit students who are novices to home health care.
Responses to the question regarding how faculty adapted clinical practicums for students with no previous home health, experience revealed a variety of approaches. Most respondents reported attempts to meet the individual needs of students. Several indicated that they adapted course objectives and experiences to meet the special needs of students, such as updating "rusty skills." One program representative indicated that agencies were specially chosen to give close student supervision, whereas two other program representatives indicated that they arrange special experiences under the direct supervision of a faculty member. Two program representatives indicated that they require the student to get the needed experience through part-time employment or a summer internship with a preceptor.
Although the novice and experienced nurses start out at very different performance levels, the authors were interested in whether they perform at similar levels. Four respondents indicated negative responses. One of those responding "no" qualified this by stating that with extensive experience, they do well. Two of the responses were positive. In fact, one of the positive respondents stated that the novice may become better because of the high-quality faculty standards compared to agency standards. Four indicated that they could not say definitely one way or the other.
Perhaps the greatest challenge for faculty members is developing and challenging the experienced nurse while, at the same time, meeting the needs of the novice nurse. Therefore, we inquired how practicums build on the skills of the nurse experienced in home health nursing. Most respondents indicated that they individualize learning activities and attempt to take the student to a higher level of skill performance. Two respondents indicated that they would even send students to other states, if needed, to find challenging and enriching learning experiences. Only one respondent indicated that their program had certain requirements for everyone in the course and then tried to meet individual needs around these requirements.
We concluded the questionnaire by asking if the respondents had anything else they would like to report about how they adapt their clinical practicums to meet the special needs of their students. Again, most emphasized the efforts they take to individualize and maximize learning experiences.
The findings from this survey indicate that these master's programs in home health nursing attempt to individualize learning experiences for both experienced and novice nurses in order to maximize learning. The advantage of this approach to clinical education is that it allows the student and faculty member to be creative in developing learning experiences that are both challenging and satisfying for the student.
We have identified two disadvantages of the individualized approach to clinical education. First, it does not allow for the development of consistent advanced practice skills that a nurse prepared at the master's level in home health nursing should be able to perform. Educators must ask the following questions:
* Are we preparing two types of graduates in home health nursing?
* Is the novice nurse, upon graduation, prepared for an entry-level position and only able to move into a management position after experience at the staff level?
* After graduation, is only the experienced home health nurse prepared to move directly into a management level position?
Starck (1987) proposed that one of the biggest problems in graduate education is the diversity in preparation for clinical practice and roles that graduates from differing programs possess. This diversity is so great that the public and employing agencies are confused about what a masters-prepared nurse should be capable of performing.
The second disadvantage of the individualized approach to clinical practicums is in the utilization of faculty and agency personnel. Individualized instruction is particularly time-consuming when working with novice nurses. Faculty and agency preceptors must try to help students develop learning objectives and experiences when their knowledge about home health care is limited. We found novice students floundering when they tried to write individual objectives. As faculty, we were consistently frustrated with the lack of depth in the novice students' objectives until we realized that it was not the ability of our students but their lack of understanding about the uniqueness of home health.
Limitations of the Survey
The main limitation of this study is that not all master's programs offering specialization in home health nursing were included. Other programs may use very different approaches to the dilemma of students having divergent backgrounds. Locating the programs with a focus in home health nursing was difficult. We contacted the NLN and the Association of Community Health Educators and were told that no listing of master's programs in nursing with a home health focus was available.
Another possible limitation of the study may have been the unwillingness of program representatives to share their specific approaches. However, only one respondent indicated a concern about sharing information about her program.
This study of the integration of novice and experienced nurses into clinical practicums found that admirable efforts are being made to individualize clinical experiences in order to maximize learning. We have identified that there may be problems with too much individualization as graduates may be performing at differing levels of skill, which is confusing for the public and employing agencies.
The willingness of respondents to share information when contacted for the survey was impressive. In fact, six of the 10 representatives sent brochures about their programs to facilitate our understanding of their curricula. One participant sent copies of the syllabi for her program's clinical practicum courses. All the respondents were interested in receiving a copy of the findings.
We encourage faculty members in home health graduate education to work together to identify creative ways to educate students in home health graduate education. Through such networking, faculty may be able to share unique clinical learning experiences outside of their immediate regions, collaborate on common research interests, and, most of all, not feel as though they are struggling to meet students' learning needs in isolation. Practice skills that students are expected to perform as clinical specialists, managers, and/or administrators can be identified, ensuring more uniformity between graduates. Thus, faculty may be able to avoid the problems of master's education reported by Starck (1987), which would be a great service to our employing agencies and to the clients we serve.
The issues discussed in this article are not unique to graduate education in home health nursing. They are also relevant to other specialty nursing graduate programs because nurses often enroll in graduate programs when they decide to make a career change from one specialty area to another. Also, many students are enrolling in master's programs shortly after completing their undergraduate degrees. Therefore, faculty teaching in other specialty areas should consider (and share) how they are handling the dilemma of clinical instruction for novice and experienced nurses.
- American Nurses Association. (1986). Standards of home health care nursing. Kansas City, MO: Author.
- Anderson, T. (1989). Priorities of expertise - What home care agencies look for in managers. Caring, 8(2), 49-54.
- Barkauskas, V.H., & Blaha, A.J. (1989). The development of graduate nursing education - A survey of home care programs. Caring, 8(2), 16-20.
- Burbach, C., Schumacher, K., Lindsay, L., & Conrad, M. (1988). How are we teaching home health nursing? American Journal of Nursing, 88, 1347-1399.
- déla Cruz, F.A., Jacobs, A.M., & Wood, M.J. (1986). The educational needs of home health nurses. Home Healthcare Nurse, 4(3), 11-17.
- Graham, B. (1989). Preparing case managers for expanded home care services. Caring, 8(2), 22-23.
- Hackbarth, D.P., & Androwich, LM. (1989). Graduate nursing education for leadership in home care. Caring, 8(2), 6-11.
- Starck, P.L. (1987). The master's-prepared nurse in the market place: What do master's-prepared nurses do? What should they do? In S.E. Hart (Ed.), Issues in Graduate Nursing Education (pp. 3-23). New York: NLN.