Since 1993, the University of Colorado Health Sciences Center/ School of Nursing (UCHSC/SON) master's program in Primary Care of Infante, Children and Adolescents (PCICA) has established 9 faculty practice sites throughout the Denver metropolitan area. Several local hospitals, school districts, correctional agencies, and institutions have collaborated with the UCHSC/SON to develop these sites that also provide clinical experiences for pediatrie nurse practitioner (PNP) students.
In 1995, the authors developed and conducted a survey to obtain student and faculty perspectives on the value of faculty practice sites for clinical learning by PNP students. The survey was also administered to the subsequent cohort in 1996. This paper reports the findings.
The Pew Health Professions Commission challenged health professions educators to make education more accountable of cost and performance and to use more ambulatory and communitybased settings (O1NeU, 1997). Communityoriented primary care experiences help students learn about people and their health in the context of home and community, help them understand the complex human dynamics of real Ufe, and help them develop the holistic perspective required for independent nursing practice (Clark & Cody, 1994; Ryan, D'Aoust, Groth, McGee, & Small 1997).
Faculty practice provides an opportunity to make the shift to community-oriented primary care. Faculty and students establish what Ryan et al., (1997) have described as a "learning community," sharing responsibility for the students' education and for promotion of the health of the community. The learning community uses faculty-student teams to create a forum for collaboration, experiential learning, integration, and synthesis. The faculty role shifts from being the authority to a mutually supportive learning relationship. The transformations in faculty role and student learning reflect a shift from competition to collaboration; from an individualistic focus to community orientation; and from systems that are hierarchical to systems that are flexible, holistic, and horizontal (Ryan et al., 1997).
The learning community is consistent with the concept of "communiversity" developed by Naomi Chamberlain to demonstrate the necessity of and opportunities for teaching and learning in the community. While working with the "sotio-health" problem of young adolescent pregnancies in Georgia in the 1970s, Chamberlain (1977) developed an innovative, multifaceted communiversity approach to the problems of pregnant teens in the context of their community. The Communiversity Education Plan was designed to bring together the community's youth and elders, lay people and professionals, in a variety of community settings. The goals for the adolescents were to acquire health information and increase self-esteem. For the program personnel and the community, the goal was to encourage a comprehensive approach to social and health problems. The scope and commitment of the communiversity approach is equally relevant to education of pediatrie nurse practitioners today as they learn and teach in the community.
Forastrom and Gray (1991) state that faculty practice is a means to facilitate the development of nursing theory, and hence contribute to the development of the discipline of nursing. They emphasize that faculty practice is not just a way to maintain clinical competence, but a means of developing and evaluating nursing knowledge. Community-based faculty practice allows faculty to implement the curriculum in a way that is both cognizant of the current demands on the profession for the delivery of care and relevant to the needs of the community.
UCHSC/SON FACULTY PRACTICE
The UCHSC/SON defines faculty practice as "the art, science and application of theory and research in service to clients, families, and communities" (UCHSC, 1994). Faculty practice includes the provision of direct nursing services to individuals and groups, as well as technical assistance and consultation to health care providers and community agencies, with the broad goal of advancing the health of individuals, groups, and communities.
The UCHSC/SON faculty members developed a faculty practice plan in 1994 to expand the range of and increase access to a variety of health and healing services (UCHSC, 1994), to promote learning communities and the sense of "communiversity," and to prioritize health promotion and disease prevention through collaboration with the community. In the faculty practice sites, nursing faculty/student teams provide state-of-the-art care for vulnerable populations. Working with faculty mentors/role models enhances students' clinical experiences. In addition, presentations in the classroom are strengthened by the faculty's close connection with current clinical problems, practice, and resources in the community. The PNP masters program faculty practice sites provide clinical learning opportunities for 120 students per year from several UCHSC/SON programs including baccalaureate, masters, doctoral, and practitioner. Hours of operation at the sites vary from 12 to 40 hours per week. In 1996, students and faculty provided pediatrie primary care in more than 10,000 client visits; in 1998, these increased to more than 16,000 visits.
Sites include nurse-managed clinics in school-based, rural, and community settings and health care in facilities for homeless families, battered women, and incarcerated youth. The first faculty practice site and learning community was established in 1993 at a middle school in response to two school health nurses concerned about students' unmet health care needs and their frequent and often inappropriate use of emergency rooms. The vision, persistence, and commitment of these two community colleagues resulted in the creation of the Carin' Clinic, a pediatrie primary care service for children up to 18 years of age. The clinic is supported by community development block grants and is operated in collaboration with the school district, local hospitals, a federally qualified health center, and the local municipality. In 1996, there were more than 1,200 visits at the Carin' Clinic; in 1997, there were 1,685 visits.
From 1993 to 1998, eight additional clinical practice sites were developed by the UCHSC/SON pediatrie nurse practitioner faculty. They included two sites in juvenile detention facilities in partnership with juvenile corrections agencies; two school-based health centers with a local school district and a children's hospital as partners; and three additional sites sponsored by another local hospital and located in a women's shelter, a county social service center, and a community resource center. Another faculty practice site was developed in collaboration with the local children's hospital to evaluate children with developmental disabilities.
Students and faculty have generated numerous relevant research questions from clinical practice, and a variety of research projects have been carried out. Students have worked on faculty research and also conducted their own research under faculty supervision. Research projects have included an assessment of the health care needs of children in a homeless shelter; an evaluation of school-based support groups for adolescents with addicted parents; a correlation of adolescents' self-esteem and smoking behavior; a student health risk behavior survey; and a correlation of passive smoke exposure and the incidence of upper respiratory infections.
Other student projects have included the development of educational materials for parents on passive smoke; assessment of parenting knowledge in a battered women's shelter; assessment of nutritional needs in a juvenile detention facility; facilitation of a community health fair, and provision of smoking cessation classes in the community. Nursing students find their classroom assignments more meaningful when they observe the information being used to serve the community, to develop grant reports, and to obtain further funding for the communities they have served.
Evaluation of Student Experiences at Faculty Practice Sites
Several models of clinical supervision are used at UCHSC/SON. These include faculty preceptors, nonfaculty preceptors, and clinical teaching associates on site working in collaboration with faculty. The two models used primarily in the master's PNP program are faculty preceptors (faculty practice sites) and nonfaculty preceptors (outside practice sites). In the faculty practice model, faculty members collaborate with the students to provide primary health care for clients in the community. The faculty member is an on-site preceptor who is responsible for direct patient care and supervision of students. With more than 12,000 visits per year in the UCHSC/SON pediatrie practice sites, PNP students now complete most of their clinical learning experiences in these faculty practice sites.
The other model, the nonfaculty preceptor model, uses nurse practitioners employed in a variety of community settings, including private practices, public health agencies, and health maintenance organizations. In this model, a master'sprepared PNP provides supervision and clinical instruction for students while functioning as a patient care provider in the practice setting. The preceptor provides feedback and collaborates with faculty and students to evaluate students' progress and learning needs.
To evaluate student experiences at faculty practice sites, students and faculty were surveyed to obtain their perceptions of these two models. The evaluation survey was conducted in 1995 and 1996, and was based on course objectives for the UCHSC/SON PCICA program. The program objectives included:
1. Identify those factors that affect how the child's health status impacts the family and environment and how the and environment and health statue in turn impact the child.
2. Examine, analyze, and begin to generate clinical pediatrie nursing research and theory as the basis for providing care to infants, children, and adolescents.
3. Delineate and manage common childhood developmental and behavioral issues and concerns within the context of family and environment.
4. Explore clinical phenomena as a means to generate relevant theory and research in the area of well child care.
5. Understand and facilitate a community needs assessment related to primary health care needs of populations at risk.
6. Describe standards of practice, the role and scope of practice of the primary health care nurse practitioner in providing care to infants, children, and adolescents with minor acute illness within the context of human care theory.
7. Identify relevant physiologic, nutritional, developmental, behavioral, cultural, and psychosocial data that serve as the basis for decision making and for constructing differential diagnosis in assessing and managing minor acute illnesses in children.
8. Begin to integrate human care theory and research in pediatrie primary health care in minor acute illness management.
The evaluation tool asked the students, and faculty to assess which type of clinical site was more helpful to the student in meeting the program objectives. The survey consisted of eight Likert scale questions and three open-ended questions asking the students and faculty to give their perceptions of the advantages and disadvantages of the faculty practices sites, the outside clinical sites and any additional comments.
At the completion of their program, 40 PNP students who graduated in 1995 and 1996 were asked to complete the survey that included clinical experiences in both faculty practice sites and "other" clinical sites with nonfaculty preceptors. Of those 40 students, 22 (55%) responded to the survey. In addition, 10 faculty members, who taught in the classroom and precepted in faculty practice sites, were asked to complete the survey of which 5 (50%) responded.
The largest proportion of students found the faculty practice sites more helpful for identifying environmental factors (43%), for generating nursing theory (57%), for generating relevant research (55%), for learning to conduct a community needs assessment related to primary health care needs of a population at risk (80%), and for integrating human care theory and research in pediatrie primary care practice (55%). That two types of sites were equivalent was indicated by 40% of the students, and another 40% thought that faculty practice sites were more helpful for learning the role and scope of the nurse practitioner. Students indicated no difference between the usefulness of the two types of sites for learning to collect data to construct differential diagnoses for minor acute illnesses. The largest proportion of students found the outside clinical sites more helpful in learning to manage common childhood developmental and behavioral issues (43%).
The majority of the faculty (60% to 80%) believed the faculty practice sites were more helpful than outside clinical sites in meeting all the course objectives except for learning to manage common childhood developmental and behavioral issues and for learning to collect data to construct differential diagnoses for minor illnesses. The unpredictable volume of clients, transient nature of the client populations, and lack of provider continuity at some of the faculty practice sites made these sites less effective in meeting these objectives.
Responses to the three open-ended questions revealed the perceived advantages and disadvantages of faculty practice and outside clinical sites from the perspectives of faculty and students. Both students and faculty agreed that the faculty practice sites were more conducive to learning and more advantageous for observing the nurse practitioner role. They believed that the faculty practice sites were preferable for beginning students who needed more time and continuous guidance from committed mentors. Faculty and students agreed that the outside sites were beneficial for learning a greater variety of diagnoses, for working with interdisciplinary teams, for observing the real obstacles to nurse practitioner practice, and for gaining exposure to potential job opportunities.
A recent study of the preceptor model for undergraduate nursing students by Nehls, Rather, and Guyette (1997) suggests that a major value of the nonfaculty preceptor model is that students have time with practicing nurses, develop oneto-one relationships, and have more time to learn. Although the roles and relationships of preceptors for undergraduate and graduate students may differ, our survey findings indicate that the faculty practice model allows faculty members to serve as preceptors and incorporates those benefits described by Nehls et al., (1997) above. In addition, it enhances the faculty role in the development of clinical knowledge, the conduct of clinically relevant research, and classroom instruction. In our experience, faculty practice sites as learning communities (Ryan et al., 1997) enhance students' learning and have a positive effect on the health of the community. Finally, they ease the logistical problems of placing graduate PNP studente in clinical sites and provide financial resources for the school of nursing.
The survey respondents' evaluation of clinical education in the PNP master's program suggested there are strengths in both faculty practice sites and outside clinical sites. Faculty and students thought that both kinds of clinical sites were valuable for PNP student learning. The learning community created by the faculty practice sites was considered as optimal for beginning students, who need more supportive learning environments and additional time to complete thorough histories and physical examinations. Consistent with the concept of communiversity, the survey respondents also considered the faculty practice sites better for assessing the community and learning the role of the nurse practitioner.
Studente reported that outside clinical sites were valuable before graduation because these sites were more like "the real world* where they would be practicing. Both studente and faculty noted that an advantage of the outside clinical sites was exposure to potential job opportunities. Faculty also believed the outside clinical sites were better for students to observe the real barriers to nurse practitioner practice.
The findings of this study represent only two cohorts of PNP students (1996 and 1996 graduates) and therefore must be interpreted with caution. In addition, several of the faculty practice sites had just been established when the survey was conducted. These newly developed sites had unpredictable patient volumes and lacked a variety of diagnoses, limiting student experiences. As these practice sites have become established, student experiences have been enriched. Thus, if the survey were repeated, students might find faculty practice sites more effective in helping them learn to collect data to construct differential diagnoses and to manage common developmental and behavioral issues.
Furthermore, in the managed care environment that has continued to evolve since the survey was conducted, outside preceptors often have more pressure to see large volumes of cliente and have less time to spend teaching students. Students' experiences in faculty practice sites may be optimal to ensure adequate time and attention to facilitate student learning. Faculty practice facilitates low studentfaculty ratios and enhances the economic viability of practitioner education by generating income from services provided. Several UCHSC/SON practitioner faculty positions are entirely funded by outside contracts for services provided in the pediatrie faculty practice sites.
Based on the findings of this study and our experience with faculty practice sites, we recommend experiences in both settings (i.e., faculty practice and outside clinical) for optimal clinical learning. Faculty practice site experiences should precede outside clinical experiences to facilitate skill development and acquisition of both confidence and competence.
We concur with Forsstrom and Gray (1991) that nurse academics must practice or perish and that faculty practice "will enrich the learning process for students in a way that will facilitate the critical, creative thinking required to provide nursing services to meet current health care challenges" (Forsstrom & Gray, 1991, pp. 296-7). We believe faculty practice is an essential component of the nurse practitioner faculty role.
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