The Congress of Nursing Practice of the American Nurses' Association is currently redefining specialization in nursing practice (Pokoray & Barnard, 1992) for a revision of the Social Policy Statement. The National Council of the State Boards of Nursing (1992) is proposing new guidelines for the licensure of advanced practice specialists. These indications on the policy level reflect change in the nature of specialty practice.
In the arena of pediatrie nursing, changes in specialty practice reflect the overall decrease in childhood mortality and an increase in sustained childhood morbidity due to advanced care technologies. These children have complex, ongoing educational, health, and social needs that are often fragmented and hard to access (Deatrick, Feetham, Hayman, & Perkins, 1993). Thus, the pediatrie clinical nurse specialist (CNS) is now more often challenged to plan and manage the care of children and their families as well as, more traditionally, to work with others who are doing so.
It behooves faculty who prepare specialists to proactively plan curricula that will successfully prepare tomorrow's graduates. The purpose of this article is to examine the present challenges involved in the preparation of pediatrie CNS in order to recommend possible future curricular changes.
Family-Focused Pediatrie Transitional Care
The Family-Focused Pediatrie Transitional Care (FFPTC) model incorporates the aforementioned concerns about children with complex health care needs and their families. It was developed recently as a model to guide graduate education, clinical practice, and research (Deatrick et al., 1993X FFPTC is based on two conceptual models that have been used extensively in research: the Nurse Specialist Transitional Follow-up Care Model (Brooten et al., 1988) and a pediatrie chronic illness model, Family Management Styles (Knafl & Deatrick, 1990). The synthesis of the two models is depicted in Figure 1.
Figure 1. Family-focused pediatrie transitional care. From Deatrick, J., Feetham, S., Hayman, L., & Perkins, M. (1993). Development of a model to guide advanced practice in family nursing, tn S. Feetham, S. Meister, J. Bell, C. Gississ (Eds.), The Nursing of Families (p. 150). Copyright 1993 by Sage Publications, Inc. Reprinted by permission.
In order to improve continuity of care, CNS interventions derived through the process of clinical decision making are based on the child and family's transitional care needs as they move across systems of care and throughout the phases in the child's illness (Rolland, 1987). The management behaviors of the family members are the day-to-day accommodations made to the child's illness, which are consistent with how the family members define their situation. The family's management style is how the family unit typically defines and manages the situation within their sxxaocultural context.
In order to formulate an agenda for curriculum change in a master's program preparing pediatrie CNS, surveys of graduates and employers were undertaken. The results of these surveys will be discussed within the context of FFPTC in order to make recommendations for the future educational preparation of the pediatrie CNS.
Continuity of Care
The goal of CNS interventions is to improve continuity of care by reducing the fragmentation of care experienced by children who have serious conditions and receive care from a number of professionals. Although the CNS intervenes primarily from the vantage point of the tertiary care setting, these interventions must be sensitive to effective and acceptable family, home, community, and school management.
Continuity of care is not new to CNS practice. However, the intensity and complexity of problems presented by children and their families, increased emphasis on home care by the family, diminished societal resources, and the failure of traditional care models calls for a paradigm shift in specially practice preparation. Traditionally, CNS education has prepared graduates to become the experts in the care of children and their families. Students were often socialized and educated to believe that families passively respond to health care situations and are in need of teaching based on the expertise of the CNS. New research has shown that families usually respond actively to illness and health care situations and quickly become the experts in their own situations (Knafl & Deatrick, 1990). On one hand, if this expertise is not recognized, the family becomes resistant over time to interventions by the CNS (Burke, Kauffmann, Costello, & Dillon, 1991). On the other hand, if this expertise is recognized, the trust in the CNS is heightened (Thorne & Robinson, 1988).
Thus, the CNS can become the family's resource by virtue of education and experience. Through collaboration among the CNS, the child, and the family, knowledge and expertise gained over time can be shared to devise the most effective management strategies for care of the child. These strategies should be acceptable to both the child and family, and effective in terms of their outcomes. In this scenario, the expertise of all individuals is acknowledged and respected. That is, the children and parents know what works best for them. The CNS knows what has worked well for other families and is familiar with the research and practice literature.
Didactic and clinical experiences in future CNS curricula can help the student learn strategies for improving continuity of care through intensive, long-term experiences with families across care sites in hospitals, home, and community settings. These long-term experiences with families will help the student understand the challenges and complexities of care as well as the strengths of families.
Clinical Decision Making
In order to care for populations across the continuum of care throughout the various phases of an illness, one of the most important processes used in advanced nursing practice is clinical decision making. Clinical decision making involves a process of gathering data about the physical, developmental, behavioral, psychological, spiritual, and socioeconomic status of an infant, child, or adolescent and his or her family, drawing a conclusion, and making a plan for nursing interventions based on these findings.
Clinical specialists are continually faced with the need to make clinical decisions. Clinical judgment is the least specifiable yet most crucial aspect of clinical knowledge (Brykczynski, 1989). While some situations with children and families seem to yield fairly straightforward decisions, the complexity of decisions is increased by aspects that are all too often uncertain. Weinstein and Fineberg (1980) list several sources of uncertainty that confound clinical decision making. These sources of uncertainty are applicable to complex patients in the practice of the pediatrie clinical nurse specialist:
1. Errors in clinical data. Due to inaccurate recording or faulty observation, data are misrepresented by an instrument or the patient. For example, the CNS may receive inaccurate data concerning a child referred by a community resource and need to reformulate the assessment. In order to do so, the CNS must be able to communicate with the child, family, professionals in the referring agencies, and professionals in his or her place of employment.
2. Ambiguity of clinical data and variations in interpretation. Information obtained by a physical examination or diagnostic procedure may be intrinsically ambiguous. In addition, observers differ in their ability to obtain thorough data through physical examination. The CNS must be able to tolerate the ambiguity and resist efforts to arrive prematurely at a decision. The CNS must trust his or her own clinical judgment in patient situations (Brykczynski, 1989).
3. Uncertainty about relationships between clinical information and the presence of disease. A patient's signs and symptoms are pathognomonic for very few diseases; therefore, the examiner must consider differential diagnoses. This is made even more complex because many of the children seen by the pediatrie CNS in tertiary care centers do not present with single diagnoses. For instance, the child with diabetes may have other autoimmune disorders.
4. Uncertainty about the effects of therapy. Treatment decisions must be weighed according to the treatments risks and benefits. The absence of active intervention is often difficult because the natural history of a disease is usually uncertain. But once the natural history of a disease is known, the CNS may learn that a disorder resolves on its own and "treatment* is unnecessary (Lipman, DiGeorge, Rezvani, 1989). It is essential to involve children and families in treatment decisions after informing them of risks and benefits.
In view of the uncertainties with which practitioners are faced, clinical decision making is both an art and a science. Graduate education must focus on the "science" of decision making by educating clinical specialists concerning the process of clinical decision making and content related to normal and diseased states. Equally important is stressing the 'art* of decision making; using the experience of the CNS and others around them to collaboratively assess children and formulate appropriate interventions.
Both the art and the science of clinical decision making can be enhanced through learning experiences in the CNS curricula that focus on two areas: 1) learning to minimize sources of uncertainty that are under the control of the advanced practitioner, and 2} acquiring the types of knowledge necessary for clinical decision making. Erroneous information gleaned by an incomplete or inaccurate assessment is a major cause of uncertainty in clinical decision making (Weinstein & Fineberg, 1980). Assessment skills are an integral part of the knowledge base needed for expert clinical judgment.
One aspect of graduate education for clinical specialists that has often been deficient is providing expertise in physical assessment skills for specialty populations, such as children with complex, serious physical problems. A survey of 75 clinical specialists demonstrated that 71% believed that having advanced skills in physical assessment would make the clinical specialist role more marketable (Elder & Bullough, 1990). With the increasing acuity, complexities, and specialized needs of patients, advanced physical assessment skills are mandatory for clinical specialists and would greatly enhance a clinical specialist program. These skills must then be blended with those previously elucidated concerning the family, home, and community to maximize the decision-making process.
To prepare for the work of clinical decision making, clinical specialists need three kinds of knowledge: clinical judgment, scholarly inquiry, and leadership (Diers, 1985). Clinical judgment begins with a strong knowledge base of basic and applied sciences; a knowledge base that will differ according to specialty. This knowledge base forms the foundation for skills in physical, developmental and psychosocial assessment. Factual knowledge and data gleaned through assessment must be applied inductively to formulate a decision.
Scholarly inquiry is an essential piece of clinical decision making that becomes integrated into this inductive process. These skills are typically learned through knowledge of research design and scholarly inquiry. In further developing a spirit of inquiry, clinical specialists will question clinical practice, investigate alternatives, and seek consultation when making clinical decisions.
A third knowledge component of decision making - leadership - is necessary for the clinical specialist to make decisions based on health policy. Through classroom discussions and leadership roles in organizations and communities, the CNS can become more aware of public and private health-related policies. These policies, in turn, demonstrate to the clinical specialist where power, money, and history lie - all salient points that increase the effectiveness of the CNS's decision making in clinical situations (Diers, 1985).
Master's education historically has attempted to incorporate leadership in the clinical specialty curricula through courses in research, management, and nursing theories (Diers, 1985). However, leadership must also be related to health policy in order to advocate for needed services for populations of children and to help individual children gain access to the complex array of services that they need. In CNS programs, content and clinical experiences related to policy decision making and its implications for clinical decision making have been neglected. Knowledge of policy is imperative for clinical decision making along a continuum of care with particular significance in the family and community settings.
A clinical specialist program incorporating advanced physical assessment skills and policy issues as keystones to clinical decision making would offer the graduate student an educational richness not available previously. This program's goal would be to prepare specialists to tackle the most complex clinical decisions with confidence and aplomb.
Preparation for Clinical Decision Making*
Survey of Graduates and Employers
In order to determine the adequacy of preparation for clinical decision making and coordinating care across the continuum of care with emphasis on home and community settings, graduates of the Nursing of Children Program at the University of Pennsylvania School of Nursing were surveyed in August 1990. In an attempt to learn which aspects of clinical decision making and coordination of care were viewed as important components of the CNS role to employers, the survey was modified for nursing administrators. Each graduate was asked to give the "administrator survey" to her or his nursing supervisor. The overall purpose of these surveys was to assess the current and anticipated demands on the practice of our graduates. These results could then be compared with the literature and the input of faculty and curricular consultants to define outcome objectives for the curriculum.
The survey was planned using the principles of evaluation research, as it was part of an overall evaluation plan (Deatrick, 1991-1994). The survey itself was based on an instrument used by Elder and Bullough (1990) in their study comparing the roles of clinical specialists and nurse practitioners and the certification guidelines for pediatrie nurse practitioners (ANA, 1990) to tap knowledge and skills relating to clinical decision making. The survey was reviewed by two practicing clinical specialists, one nursing administrator, and two nursing faculty members. Alterations were made in order to increase its clarity.
The clinical specialists were asked, "Based on the way you currently practice, how do you believe graduate education prepared you to function in these areas?* The answer choices were "adequately prepared," "needed more knowledge," or "not expected in my practice." The nursing administrators were given a survey of the identical areas of clinical decision making and coordination of home/ community care, but were asked, "hi your agency, in which of the following areas should a prospective clinical specialist have a strong knowledge base?" The administrators were asked to rate each area in importance on a five-point Likert scale ranging from "extremely important* to "not expected of a CNS in this agency." The graduates were also queried on their opinion of four professional issues.
The survey was mailed to all graduates (N- 78) of the Nursing of Children Program of the University of Pennsylvania School of Nursing from 1984 to 1989. Each graduate was asked to give an administrator's survey to her nursing supervisor. Five CNS surveys were returned because of incorrect addresses, and three were returned without being completed by graduates who were not currently employed. The graduate group returned 28 completed surveys and nursing administrators returned eight. The practice settings of the graduates (many checked more than one practice setting) were 93% hospital inpatient, 43% hospital outpatient, 18% school of nursing, and one graduate practiced in a community setting. Sixty-eight percent of the respondents were employed as clinical specialists, 18% were working as staff nurses, 14% were faculty, and there were two head nurses and one staff development instructor. Data for each item were used if respondents stated that they used specific knowledge and skills in their present role in order to make a judgment relative to their preparation (Table 1).
Adequacy of Preparation for Clinical Decision Making
As Table 1 shows, a substantial number of graduates believed they were prepared inadequately for clinical decision making, especially in three of the 10 areas of clinical decision making surveyed (items 2, 7, 8). These areas were physical assessment, using knowledge of physiology and pathophysiology to order appropriate lab studies, and using knowledge of norms and baselines in analyzing data and establishing diagnoses.
Although the number of administrators responding was small (n = 8), it is of interest to note that their responses were similar to those of the CNS. That is, 100%, 88%, and 75% respectively stated that it was extremely important or very important for a prospective CNS to have a strong knowledge base in the above mentioned areas of clinical decision making.
Adequacy of Preparation for Coordinating Home/ Community Care
As Table 2 shows, the graduates who coordinated home/community care as part of their practice (ra = 25) believed they were inadequately prepared in general. The preparation was particularly inadequate in four out of 12 areas. Sixty-eight percent needed more knowledge to assess financial needs and resources; 73% to identify state and federal resources; and 68% needed supplementary knowledge to help access additional resources once the resources were identified. Sixty-eight percent of graduates stated that they were inadequately prepared to use knowledge of health policies for clinical decision making (Table 2). The administrator survey was not helpful in this area because many of the responses to these issues were not included.
Opinions on Professional Issues of the CNS
All (100%) respondents stated that nurse practice acts should include special provisions for the CNS. All but one graduate believed that clinical specialists should receive third-party reimbursement for outpatient care. Concerning revision of the CNS program, 75% believed that nurse practitioner preparation should be included and 79% stated that management of home/community care should be included. Of note is that four nurses underscored the importance of nurse practitioner preparation and one graduate stated that she returned to school for practitioner education because she felt inadequately prepared to perform physical assessments.
The literature, current trends in practice, professional organizations, and the graduates of the program who responded to a survey have indicated that clinical decision making and coordination of care across the continuum have become essential components of the CNS role. While limited to a small number of graduates from one program, the graduate survey documented the need for refinement and expansion of a graduate curriculum in Nursing of Children at the University of Pennsylvania to include advanced clinical decision making and coordination of care across the continuum of care. However, these results may have implications for other educators as they plan curricula, for prospective students as they choose programs, and for employers as they create positions and hire graduates.
Preparation for Coordinating Home/Community Care*
It is recommended that CNS programs may benefit from a broadening of their focus to ensure that graduates will be marketable and adequately prepared to assume these roles. In fact, a recent survey of 13 major medical centers throughout the eastern seaboard revealed that the nine respondents overwhelmingly supported this evolution of the CNS role. In addition, they expressed a firm commitment to hiring such a graduate (Richmond & Keane, 1992X
Graduates of this pediatrie nursing program earmarked two major areas that were deficient m their graduate education:
* skill in performing complete physical assessments with the concomitant knowledge of ordering laboratory studies and analyzing data to determine diagnoses, and
* knowledge of resources and policy to coordinate care across the continuum.
While elements of these competencies have historically been present in the CNS role, the unique combination and refinement of skills now required for the care of children and their families represents an evolution in the CNS role.
These role competencies are critical skills for implementing FFPTC since the majority of children who are patients in specialty practice new require interdisciplinary care across a continuum from the tertiary setting into the home and the community. From the vantage of their typical practice arena - tertiary care - and from relatively new practice areas in community settings, clinical specialists can provide this continuity of care. The clinical specialist, in fact, has a special interest and access to children and their families because the CNS often sees them at major transitions in then- treatment, when they may be most amenable to intervention.
Studies have indicated that the education and roles of clinical specialist and primary care nurse practitioner are comparable (Elder & Bullough, 1990; Forbes, Raison, SproBs, & Kozlowski, 1990). The ANA clinical specialist and nurse practitioner councils discussed the roles and stated, "the similarities are many and the differences few* Sparacino & Durand, 1986, p. 2). Some have suggested merging the two roles (Elder & Bullough, 1990; Starck, 1987). A merging of the roles, however, is not proposed due to the differences between primary and specially orientations to practice and the inability of most of today's programs to prepare graduates in both areas due to time constraints inherent in the curricula of many programs.
Instead, greater emphasis on physical assessment and clinical decision making skills is proposed to intensify the traditional roles of the clinical nurse specialist. Therefore, graduates will no longer be deficient in the areas of clinical decision making, will be more marketable, and be better prepared with extensive competencies to manage the most complex, specialty health care needs of children and their families. Of course, our overall plan for the curriculum includes an evaluation of the actual competencies of our graduates in a survey of our graduates and their employers one and five years after graduation.
FFPTC will incorporate the leadership knowledge needed for clinical decision making and care across the continuum for children and their families. Education about assessing, identifying, and accessing resources as well as institutional, state, and federal policies will be an integral part of this framework. Furthermore, inclusion of these areas in the educational preparation will help to formalize these areas of practice for the CNS.
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Preparation for Clinical Decision Making*
Preparation for Coordinating Home/Community Care*