Nursing as a profession and nurses as individual practitioners have a responsibility to be responsive to the changing needs of society (American Nursea Association [ANA], 1995). The economic realities confronting the health care system, the shift in emphasis from diagnosis and treatment of disease to prevention and health promotion, expanding technology, and the changing demographics of American society all have implications for nursing practice, research, and education. Nurse educators are challenged to provide curricula and clinical experiences that prepare nurses to practice in the future health care environment.
Meeting the Health Care Needs of Children
Despite recent rhetoric declaring the American economy to be stronger than it has been in decades, specific subgroups within the population remain vulnerable to the effects of unemployment, poverty, and unequal access to a variety of basic rights. Children, as one of those subgroups, have significant risk factors impacting their health and well-being. In 1994, 15 million children, 22% of all United States children, lived below the poverty level. Thirteen percent of all United States children were without health insurance in 1993 (Kids Count Data Book, 1996). Children growing up in poor families and those without health insurance are lees likely to have access to health care, are lese likely to be fully immunized (Kids Count Data Book, 1996), and have higher frequencies of a variety of health conditions (Star-field, 1992). In addition, the number of United States children with a chronic condition has doubled since 1960 (Betz, 1993). An estimated 31% of children younger than age 18 have one or more chronic conditions (Jackson, 1996). While the overall incidence of most childhood chronic conditions has not changed significantly over the past 20 years, long-term survival requiring continued, complex care has increased dramatically (Jackson, 1996). There is a greater need than ever to provide adequate health care services to alt children.
In the Healthy People 2000 project, an agenda for health care to the end of the 20th century and into the 21st century was set forth. It providea a vision for achieving improved health care for all Americans by setting 22 priority areas under the general headings of preventative services, health protection, and health promotion. The health care of children and families is an explicit part of each priority (United States Department of Health and Human Services, 1995). With the goals of Healthy People 2000 as a guide, the ANA's proposal for health care reform provides direction for future nursing practice (ANA, 1994). In the proposal, the ANA calls for specific preventive services for infants and children, as well as primary care, hospital care, emergency treatment, inpatient and outpatient professional services, and home care services for all Americans. With the shift in focus to community-based health care and with the reorganization of health-care services, many nurses in a variety of settings will play a role in providing preventive, restorative, end rehabilitative health care to children and families.
Despite the charge to address the health care needs of children and the call for nurses to participate in the delivery of care to vulnerable populations, pediatrie nursing as B specific, separate entity in undergraduate curricula across the country is vanishing (Betz, 1991). Aa greater emphasis is placed on acute and community care nursing, clinical rotations hi pediatrie nursing are being reduced and, in some situations, eliminated altogether, as pediatrie content is integrated into other areas of the curriculum (Betz, 1993). The result could well be a decrease in the number of nuraes interested in aod prepared to provide care for children and their families. This is a disturbing response to the mandate to provide more services to children.
Essentials of Professional Pediatrie Nursing Education
Two projects completed in the past 12 years provide guidance for pediatrie undergraduate education. In 1986, the American Association of Colleges of Nursing (AACN) presented the resulta of the first comprehensive, national effort to define the essential knowledge, practice, and values baccalaureate nurses should possess (AACN, 1987). In the resulting document, "Essentials of College and University Education for Professional Nursing," the major roles of nursing in wellness and health promotion, hi acute care, and in long-term care for chronic illness, as well as the values, knowledge, and BkUIs necessary to fulfill those roles were defined (AACN, 1987). A key recommendation of the report was that graduates of professional nursing programs possess the nursing knowledge and clinical skills necessary to think critically and to make clinical judgments. Clinical judgments can be made only by individuals who have an adequate knowledge base and who are adept at performing related clinical and professional skills and nursing interventions (Johnson, 1987). For this reason, specific recommendations were made regarding the knowledge and skills that should be included in every program that prepares professional nurses. It also was recommended that specific opportunities be included in the educational program for students to practice clinical judgment skills (AACN, 1987).
In 1995, a group of pediatrie nurse experts from the University of Wisconsin and the Society of Pediatrie Nurses (SPN), presented Standards and Guidelines for Pre-licensure and Early Professional Education for I he Nursing Care of Children and Their Families (Pridham, 1995). The standards were developed to support the pre-licensure education of professional nurses in the care of children and families. The standards and guidelines are based on the following assumptions:
* Pediatrie nurses must provide family-centered, community-based, and coordinated care sensitive and responsive to the beliefs, practices, and strengths of cultural groups.
* Much of the care of children will be shifted from hospital to community settings.
* Every graduate of a professional nursing program must have course work in life spa n development and physical growth.
* These goals can be implemented across all settings where professional nursing education occurs.
Using Bronfenbrenner's (1993) theory of the ecology of human development as a framework, the pediatrie nurse experte defined the knowledge needed for the nursing care of children and their families. The knowledge is structured as 11 goal statements, which provide standards of practice for novice pediatrie nurse:
Child, family, and societal faeton:
* The nurse will integrate knowledge of the unique anatomic structures, physprocesees of children from birth through adolescence in assessments and in plana, interventions, and evaluation of care.
* The nurse will use opportunities to influence positively the health behavior of children and their families.
* The nurse will provide supportive care for children and families experiencing Réparation, lose, and/or bereavement.
* The nurse will use knowledge of how the economic, social, and political environment influences the child's health and the family's care of the child to: (a) make assessments, plan stratégie*, and implement approaches to core of the child that are in accord with the family's economic and social situation and available resources; and (b) work with others in the community to make and implement plane for the health-care needs of children.
Clinical problema or areas:
* The nurse will provide and promote safety te prevent injury and support the development of the child.
* The nurse will make assessments, plan strategies of care, and intervene in ways that promote the growth and development of the child with a chronic condition or disability, support the ChUd1S family and family's management of care, and promote a healthy family lifestyle. Evaluation of nursing care is a part of this proceas.
* When providing care to children with acute illness or injuries and their families, the nurse will make assessments, plan strategies of care, and intervene in ways that promote the growth and develchild's and family's management of care. Evaluation of mining care is a part of this procesa.
* The nurse will use the family-centered approach to: (a) assess the needs, plan and implement interventions, and evaluate outcomes relevant to the healthcare needs of children in partnership with children and their families; (b) work with other health care providers and the family to promote coordinated service delivery; and (c) advocate for family-centered care of children.
* The nurse will participate in developing and working within service delivery systems to support practice that U consistent with principles of a family-centered approach.
* The nune will knowledge and integrate into health can the beliefs practices, and values of cultural groups defined by geography, race, ethnicity, religion, or socteeconomk statua.
* The nurse will communicate effectively with child and family.
* The nune will respond to an ethical, moral, or legal dilemma concerning the child's health in ways that promote Uw development of familles and children, assist them in making decisions, end support them in implementing the deci sions (Pridham. 1996, p. 10-12).
Implications for Pediatrie Undergraduate Education
To practice nursing in the current environment, nurse graduates roust have a well-developed knowledge base, technologic skills, and the cognitive skills to think critically and make clinical judgments (Oermann, 1994). Because the care of children and families may be required in a broad base of clinical practice «tea, all nurses should possess at least a beginning level of knowledge and skill related to pediatrie nursing. Specific prescriptions for undergraduate nursing education are not provided in either of the above documente. However, recommendations are made concerning the specific knowledge, clinical experiences, and nurse educators necessary to prepare nurses to care for children and families. Taken together, the two documents can be used to guide the development of pediatrie undergraduate education programs that prepare pediatrie nurses to work in the current health care environment.
Specific Knowledge. Specific knowledge based on courses in the aaencea, humanities, and nursing is neceaaary to think about nursing problems. In the AACN ( 1987) document, that knowledge is identified. There is a relationship between the knowledge necessary to care for adulta and that necessary to care for children. Nurse studente build that common base of knowledge as they progrese through their education. However, domain-specific knowledge ia also required, both for critical thinking (Kataoka-Yahiro & Saylor, 1994) and for technical akills (Oermann, 1990). For nurses who will care for children and their families, that basic, common knowledge base must be expanded to include knowledge of the unique anatomy and physiology, growth and development, and psychology of children and adolescents (Pridham, 1995). In the SPN document the basic knowledge necessary to provide family-centered nursing care for children and their families is clearly defined (Pridham, 1995). Without this specific knowledge, the nurse student will not be able to develop critical thinking or technical skills in relation to children and families.
Clinical Experience. Benner (1984) states that practical knowledge in an applied discipline is only developed through clinical experience. Students must have opportunities to apply the knowledge gained in the classroom setting and to practice making decisions. To think critically, the nurse student must develop the ability to recognize patterns and cues and make judgments about the relevance or irrelevance of the observations. This is developed only through experience with similar and contrasting situations (Benner, 1984). Clinical experiences in a variety of settings permitting the nurse student to apply knowledge learned in the classroom are supported in both the AACN and the SPN documents. To prepare nurses to care for children and families, that experience must be with children and families.
Limited research has been conducted focusing on the relationship between din' ical experiences and the development of critical thinking (Graham, 1995). However, expertise takes time to develop (Benner, 1984). While it is not the intent to develop expert nurses at the completion of a baccalaureate program, it makes sense that providing clinical time to practice in the clinical area will provide a sound foundation for critical thinking. This empirical assumption is supported by Graham (1995) , who found that students with more time in the clinical area and more actual time with patienta showed the most improvement in their scores on a measure of critical thinking.
Time for clinical practice is an important factor when other educational outcome measures are considered as well. Carrol! (1989) found that role depravation scores (a measure of reality shock) increased significantly after a major curriculum change in which clinical practice time was decreased by 44%. The researcher concluded graduates of the revised curriculum might be less prepared to cope with the real-world work of hospital nursing than previous graduates who had more clinical experience.
Learning technical, psychomotor skills is an important part of nursing education, separate but related to the cognitive knowledge necessary for nursing practice. In the AACN (1987) document, a list of specific, clinical, psychomotor skills neceseary for the beginning practitioner of adult nursing is presented. Although specific psychomotor skills are not presented in the SPN document, many of those same skills are implicit in the outcome criteria presented (Pridham, 1995). Both practice over time and feedback from competent teachers are necessary for the development of these skills (Oermann, 1990). Past experience is an important factor in peychomotor skill development (Oermann, 1990). In some situations, the skills learned while caring for adults can form the basis for learning skills necessary for pediatrie nursing. However, children's unique anatomy and physiology, growth and development, and psychology impact skill development (Pridham, 1995). An opportunity to practice and develop the skills in a pediatrie clinical setting is essential.
Students themselves recognize the importance of clinical experience. In a study in which the perceived competency lévele of graduating seniors were examined, Mozingo, Thomas, and Brooks (1995) found that students felt they lacked competence in their clinical/technical skills. The students overwhelmingly expressed the need for more opportunity to practice skills within the nursing program.
Although pediatrie nursing education was not specifically examined in any of these studies, the results provide support fot the argument that tfee tìnte in pediatrie rotations should not be decreased, and in fact in many instances, should be increased. Further research is needed to define the optimal clinical time necessary for nurse students to develop beginning critical thinking skills and clinical competence for caring for children and families.
Nnree Educatore. A review of the literature related to teacher behaviors and characteristics leads te the conclusion that there are two important dimensions of clinical teaching effectiveness: the teachers' knowledge of the practice area in which they are teaching and the teachers' own clinical competence (Oermann, 1996). It is clear that effective clinical teaching requires knowledgeable and clinically competent faculty who are able to communicate that knowledge to studente. This supports the recommendations of Pridham (1995) that pediatrie faculty posses the following characteristics:
extensive clinical experience and/or advanced education in the nurtíng core of children and families; experience in caring for children and families in B variety of settings; demonstrated commitment to the care of children and families; competence in problem solving; concerning care issues for children and their families; and understanding of the teaching-learning procese for the nuraing of children and their families (p. 9).
Clinical faculty guide nurse students in the development of the cognitive, psychomotor, and affective skills necessary to the care of children and families. It is essential that they are experts in the care of children and families.
Changes in health care delivery in the United States put nurses in a position of providing care to children and families in a variety of settings. With a shift te family-centered, community-based care, many nurses will care for children and their families during their nursing careers. Programs that prepare professional nurses must provide an opportunity for nurse students to develop the cognitive, psychomotor, and affective competencies necessary to provide this care. This can best be accomplished by providing a distinct, pediatrie experience. This experience must include classroom instruction regarding the unique body of knowledge related te the care of children and families. It also should offer opportunities to apply and practice the knowledge and skills learned in the classroom in a «ariety of clinical settings, under the direction and supervision of expert pediatrie nurse educators.
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