UNDERGRADUATE PEDIATRIC NURSING EDUCATION: ISSUES, CHALLENGES AND RECOMMENDATIONS ANN MARIE MCCARTHY, PHD, RN, FAAN⁎
AND
JANET S. WYATT, PHD, RN, FAANP†
The topic is a national review of content and clinical experiences in undergraduate pediatric nursing education with recommendations for strengthening the pediatric nursing curriculum. American Association of Colleges of Nursing member programs (N = 596) were surveyed with 344 schools responding. A 39-item survey collected school demographics, faculty characteristics, pediatric classroom and clinical information, and actual and perceived barriers to implementing the pediatric curriculum. Recommendations for change were offered by participants attending the 2011 Institute of Pediatric Nursing Nursing Forum. A mean of 33 (SD = 27) total undergraduate faculty included an average of 3.1 (SD = 3.11) faculty with graduate specialization and/or recent clinical experience in pediatrics. Within a mean of 43 (range = 0–136 hours) pediatric classroom hours, more than 59% of programs reported 2 hours or less in pediatric genetics, environmental health, and child nutrition. Content focused on acute and specialty care with programs using pediatric inpatient medical (68%) and surgical units (40%) for clinical learning. Recruiting pediatric faculty was a common issue and reported as extremely (23%) to moderately difficult (26%). Competition for clinical practice sites (76%) was a reported barrier. Adjustments in the pediatric undergraduate curriculum are recommended to highlight current health issues experienced by children including expansion of clinical learning experiences to settings where children live, learn, and play. (Index words: Pediatric nursing education; Institute of Pediatric Nursing) J Prof Nurs 30:130–138, 2014. © 2014 Published by Elsevier Inc.
F
OR THE PAST 3 years, the Institute of Pediatric Nursing (IPN) (www.ipedsnursing.org) has assembled 50 leaders from more than 15 national pediatric nursing organizations and 10 major children's hospitals at an annual, invitational forum. As a nonprofit “organization of organizations,” the IPN serves as the collective voice for pediatric nursing, developing activities and initiatives in support of pediatric nursing and the health care needs of children and their families. In 2010, participants at the IPN Pediatric Nursing Forum (forum) identified that the depth and breadth of pediatric nursing content in undergraduate nursing education was a significant concern for pediatric nursing leaders in education and practice. With limited exposure to care of ∗President, Institute of Pediatric Nursing and Associate Dean for Research, The University of Iowa College of Nursing, Round Hill, VA. †Consultant, Institute of Pediatric Nursing, Round Hill, VA. Address correspondence to Dr. Wyatt: Consultant, Institute of Pediatric Nursing, 35460 Sassafras Drive, Round Hill, VA 20141. E-mail: jwyatt@ ipedsnursing.org 8755-7223/13/$ - see front matter 130 http://dx.doi.org/10.1016/j.profnurs.2013.07.003
children during their undergraduate education, new graduates may be less likely to enter jobs focused on children, impacting the development of future pediatric nurses and leaders. As a sign of decreasing interest in pediatric nursing, recent national data has documented a growing national decline in enrollment in graduate advanced practice pediatric nursing programs (American Association of Colleges of Nursing [AACN], 2012a, 2012b). In addition, nursing leadership from children's hospitals across the country have discussed difficulties recruiting expert pediatric nurses with the knowledge and skills needed to assist children and families with the growing burden of chronic illness and emerging complex behavioral health issues. Additional discussion at the forum suggested several areas of potential concern. Nursing educators have reported difficulty in recruiting and retaining pediatric nursing faculty, decreased curricular content focused on children and families, and challenges identifying appropriate pediatric clinical placements for undergraduates. Children with acute health care problems now spend
Journal of Professional Nursing, Vol 30, No. 2 (March/April), 2014: pp 130–138 © 2014 Published by Elsevier Inc.
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less time in acute care settings, decreasing availability of clinical practicum sites. However, a lack of data on current pediatric content in undergraduate curriculums and clinical practices was identified. To address this knowledge gap and to assure a pediatric nursing workforce in the future, IPN leadership targeted their efforts in 2011 on clarifying the current state of pediatric nursing in undergraduate bachelor of science in nursing (BSN) programs and working together with IPN participants to review findings and propose recommendations to strengthen pediatric nursing education. The purpose of this article is to describe the results of a national survey to identify the current trends and challenges in providing pediatric nursing education in baccalaureate (BSN) nursing programs and to utilize these findings to propose recommendations to strengthen undergraduate pediatric nursing education. The study was designed as a partnership between the AACN and the IPN. Specific objectives of the study were to describe (a) the characteristics of the schools/colleges and the faculty currently teaching the didactic and clinical pediatric content, including challenges in recruiting faculty, (b) the didactic content and clinical experiences in the pediatric curriculum, including use of alternative teaching strategies, and (c) barriers encountered in providing pediatric content in AACN member BSN programs. An initial goal of this research was to incorporate the information obtained in this survey together with the expertise of pediatric nurse leaders within the IPN to provide creative guidance to baccalaureate nursing programs to strengthen delivery of content related to nursing care of the pediatric population. As undergraduate nursing education programs establish the AACN's Baccalaureate Essentials (AACN, 2008) as the framework and structure for undergraduate nursing education, development of vital undergraduate pediatric nursing resources will provide the means necessary for faculty to assure quality undergraduate pediatric nursing education.
completed the entire survey. More than 81% of faculty (247) completing the survey reported that they had pediatric nursing teaching responsibilities. Analysis of responses from those completing the survey and those who did not complete the survey revealed that those who fully completed the survey came from programs with more faculty with recent clinical pediatric clinical experience (3.2 vs. 2.1, t = 2.19, P = .03) who also had stand-alone pediatric nursing courses (51% vs. 35%, χ 2 = 6.29, P = .04).
Methods
Data Management and Analysis
Sample
Analyses were completed using descriptive statistics appropriate for the type of data. Frequency and crosstabs were used for categorical data, and means, standard deviations, medians, and ranges were used for continuous data. For group comparisons, chi-squared test, t tests and analysis of variance were used as needed. Correlations and regression were used to further explore relationships and explanatory factors.
The collegiate AACN member e-mail list of undergraduate nursing programs (N = 596) provided the sample for this descriptive survey research. Four hundred sixty responses were downloaded from the SurveyMonkey© platform that hosted the survey. Based on city, state, IP address, financial support, location, and type of program, multiple responses from within the same school were identified with the most recent entry retained. Removal of duplicate responses resulted in three hundred ninety-four (66% of the schools) responses from schools. Fifty schools were eliminated from the analysis because they either did not indicate more than 10 students (n = 4) or did not complete the first 14 demographic questions (n = 46). The final sample prepared for data analysis consisted of responses from 344 schools or 58% of the AACN member schools. Not all items were completed by all respondents. Of the 344 schools, 275 (88%)
Measure The survey was developed with national input from senior pediatric nursing educators and included input from the IPN Board of Directors and the senior director of education policy at the AACN. As the survey was developed, using the on-line SurveyMonkey format, it was reviewed by the IPN Board and additional pediatric nursing faculty experts and revised accordingly. The final version of the survey consisted of 39 questions, which included a combination of closed and open-ended questions. The survey was divided into five sections covering demographic items that provided a description of the college/school of nursing, the faculty, didactic curriculum content, clinical experiences, and perceived barriers to implementation of undergraduate program pediatric learning objectives.
Procedures E-mails inviting participation in this research were sent to the 596 undergraduate program directors or deans included in the AACN membership database. Participation in the survey was open for approximately 1 month (August 18 to September 16, 2011). Deans and program directors were asked to forward the survey to the lead faculty member responsible for managing delivery of pediatric nursing content in the undergraduate program. Two e-mail reminders were sent to all undergraduate program directors during this period.
Results Colleges/Schools The description of the participating schools is summarized in Table 1. The geographic distribution of schools responding to the survey was similar to the distribution of AACN member schools, although there were 6% less responding from the southeast and 10% more from the midwest. The majority of responding schools were not part of an academic health care center (77%), offered
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Table 1. Characteristics of Responding Schools Characteristics (n = 344)
Number (%)
Geographic region Northeast 62 (18.0) Southeast 103 (29.9) Midwest 140 (40.7) West 38 (11.0) University health care consortium or academic health center No 266 (77.3) Yes 78 (22.7) Financial support Private (nonreligious) 87 (25.3) Public 173 (50.3) Religious 84 (24.4) Location Rural 66 (19.2) Suburban 103 (29.9) Urban 175 (50.9) Type of program Undergraduate and graduate 249 (72.4) Undergraduate only 95 (27.6) Size of PROGRAM Small: ≤ 150 students 91 (26.5) Medium: 151–300 students 123 (35.8) Large: 301–500 students 76 (22.1) Very Large: 501 + students 54 (15.7)
both graduate and undergraduate education (72%), and were in urban areas (51%). Financial support of the schools was evenly divided between public (50%) and private (25% religious and 25% nonreligious). The size of the programs was based on the number of full- and parttime students in the undergraduate nursing program. The range was large, with the programs reporting between 11 and 2,500 students (X = 312.5; SD = 257.9). To facilitate data analysis, we divided the programs into four size categories (small, medium, large, and very large).
Faculty Participants reported a wide range of the number of faculty at their schools, with a combined number of fulland part-time faculty ranging from 0 to 200 with a mean of 33 (SD = 27). The reported undergraduate nursing faculty to student ratio ranged from 1:1 to 1:70 with a mean of 1:12 and a median of 1:10. Survey results noted that faculty teaching at schools with only undergraduate programs had smaller faculty-to-student ratios. Data were collected to describe the number of faculty with graduate pediatric specialty preparation (master's degree and higher) and faculty reporting recent pediatric nursing clinical (nonteaching) experience. The average number of faculty with a master's degree or higher with a specialization in pediatrics was 3.1 (SD = 3.11) with a median of two pediatric faculty per school. Similarly, the average number of faculty (with or without graduate specialty preparation) reporting recent (past 2 years) pediatric nursing clinical experience not including student supervision was 3.1 (SD = 2.91) with a median of two faculty per school. Programs were also asked to
respond to a three-part question designed to determine the total number of undergraduate faculty with pediatric teaching responsibilities for classroom only (a), clinical only (b), and combined classroom and clinical (b) teaching responsibilities. More than a third of participants (107) selected the option “5 + faculty” to describe the number of faculty with teaching assignments in each of these three areas. These responses suggest that undergraduate programs consistently employ additional, nonpediatric specialty faculty to teach undergraduate pediatric classroom and clinical content. When assessing interactions, very large schools in the northeast with both graduate and undergraduate programs and programs that were part of academic health centers (AHC) tended to have twice as many faculty with Masters of Science in Nursing (MSN) degrees or higher in pediatrics and faculty with recent pediatric clinical experience than small, non-AHC, undergraduate-only programs and programs in the southeast. Data describing the distribution of faculty with graduate pediatric specialization and/or faculty with recent (nonteaching) pediatric clinical experience are profiled in Table 2. In order to better understand faculty issues, respondents were asked to report their experiences related to recruitment of qualified pediatric faculty. Only 26% of the schools reported no difficulties with recruiting qualified pediatric nursing faculty; more than half (52%) reported extreme or moderate difficulty. No associations were found between difficulty with recruiting faculty and geographic region, location, size of program, financial support, type of program, or affiliation with AHC. An open-ended question allowed responders to provide additional comments to provide a better understanding of the issues associated with recruiting pediatric faculty. Half of the participants responded to this question. Qualitative analysis of these responses revealed three major issues and included difficulty finding qualified part-time and full-time pediatric nursing faculty (44%), low salary and competition with clinical salaries (18%), and needing to hire and train their own nursing graduates to fill pediatric teaching needs and develop creative arrangements with hospitals with pediatric inpatient units, including children's hospitals (5%).
Curriculum The total number of pediatric nursing didactic class hours ranged from 0 to 136 hours with an average of 43 hours. Pediatric didactic courses were primarily offered as an oncampus option only (81%) versus courses offered both on campus and Web-based/distance learning (19%). Programs primarily had stand-alone pediatric nursing courses (49%), with fewer describing integrated courses (31%) or both (20%). A list of 11 broad pediatric nursing curriculum content areas was developed, and faculty were asked to report the number of classroom hours within the entire undergraduate curriculum that were devoted to these topics. Table 3 summarizes the number of classroom hours and specific content covered in the didactic
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Table 2. Number of Pediatric Nursing Faculty in Undergraduate Nursing Programs Faculty with graduate degree in pediatrics and faculty with recent (within 2 years) pediatric clinical experience by size of program, geographic region, type of program, and academic health center Master's or higher degree with graduate specialization in pediatrics
Recent pediatric nursing clinical (nonteaching) practice experience
Mean (SD)
Mean (SD)
2.0 (2.14) 3.0 (2.61) 3.6 (3.07) 4.9 (4.49) F = 11.47, P b .001
2.0 (1.97) 2.8 (2.33) 3.7 (2.81) 4.6 (4.37) F = 12.06, P b .001
4.4 (4.50) 2.8 (2.49) 2.7 (2.41) 3.4 (3.47) F = 5.10, P = .002
4.4 (4.18) 2.8 (2.47) 2.6 (2.30) 3.3 (2.99) F = 5.85, P = .001
3.8 (3.39) 1.5 (1.18) t = 9.07, P b .001
3.5 (3.13) 1.9 (1.77) t = 4.76, P b .001
2.7 (2.31) 4.8 (4.63) t = 5.42, P b .001
2.7 (2.22) 4.4 (4.28) t = 4.89, P b .001
Size of program Small Medium Large Very large Geographic region Northeast Southeast Midwest West Type of program Undergraduate and graduate Undergraduate only Academic health center No Yes
pediatric courses and any other pediatric nursing content delivered in other courses within the undergraduate curriculum. More than 59% of programs reported 2 hours or less class time within the entire undergraduate curriculum in each of the following content areas: pediatric genetics, environmental health, and child and adolescent nutrition. More than 47% of programs reported 2 hours or less of pediatric content in pediatric behavioral/mental health, family health/ parenting, and community/school health. The most frequently included content areas were acute care, with 47% reporting more than 11 hours in their curriculum, and chronic illness/specialty care, with 33% reporting 11 or more hours. When asked what other courses, such as health assessment, community health and psych/mental health courses, might include
pediatric content, 25% of the programs indicated that either they did not have these courses or there was no pediatric content hours in these courses. Only 42 programs (12%) offer an elective pediatric nursing course. The total number of reported pediatric clinical hours ranged from 0 to 225 hours with a mean of 83, median of 116, and mode of 90. Schools were asked to select the clinical placement sites that they most commonly used from a comprehensive list of 16 different pediatricfocused clinic settings ranging from newborn care to schools, mental health clinics and hospitals, and emergency care settings. The most frequently used pediatric clinical sites were (a) pediatric inpatient medical units (68%), (b) pediatric inpatient surgical units (40%), (c) pediatric specialty care units (19%), (d)
Table 3. Total Curriculum Classroom Hours by Pediatric Nursing Undergraduate Content (N = 315) Number of hours (largest percent of content in bold) Content and topics (alphabetical)
None, %
1–2, %
3–4, %
5–6, %
7–8, %
9–10, %
11–12, %
13 +, %
Child/Adolescent behavioral/Mental health Child/Adolescent growth and development Child/Adolescent nutrition Community and school health Family health and parenting Health promotion/Well child care Pediatric acute care Pediatric chronic illness/Specialty care Pediatric critical care/Emergency care Pediatric environmental health Pediatric genetics
6.7 1.0 2.9 9.2 5.4 1.0 0.6 1.0 4.8 5.4 7.9
41.0 18.4 56.5 38.1 42.9 15.6 6.7 11.1 32.4 57.8 67.3
29.2 32.1 27.3 26.3 27.3 29.5 11.7 17.1 30.2 23.2 18.7
11.7 21.6 7.0 10.5 12.7 22.5 11.7 17.5 12.1 7.9 2.5
5.7 7.6 3.5 7.3 5.1 12.7 11.1 9.8 6.7 3.8 1.6
1.9 5.7 2.5 2.2 1.6 7.0 10.8 10.5 5.1 1.3 0.6
1.9 4.8 0 1.9 1.6 4.8 13.7 12.4 3.8 0.3 0.3
1.9 8.9 0.3 14.4 3.5 7.0 33.7 20.6 5.1 0.3 1.0
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pediatric intensive care units (10%), and (e) elementary schools (10%). Programs also reported their experiences (within the past 2 academic years) in securing pediatric clinical practice sites. It was extremely difficult for 24% of the schools, moderately difficult for 29%, somewhat difficult for 32%, and not difficult for 16%.The only statistically significant factor associated with difficulty finding clinical sites was with difficulty in recruiting qualified pediatric faculty (P b .001). If schools indicated that it was extremely/moderately difficult to find clinical placements, 67% also identified that it was extremely/ moderately difficult to recruit qualified faculty. Respondents were also asked to report the range of resources and alternative teaching strategies used to supplement or support classroom lectures and clinical experiences. In the didactic course, pediatric case studies (82%) and multimedia strategies (61%) were moderately or highly used, whereas in the clinical sites, pediatric case studies (58%) and mannequin models (58%) were moderately or highly used. Mannequin models were infrequently used in the classroom by 72% of the programs. Other strategies that were infrequently used or were not used at all either in the classroom or in clinical sites include podcast independent learning (class, 93%; clinical, 97%), multidisciplinary learning (class, 67%; clinical, 88%), and self-directed learning (class, 53%; clinical, 63%). Respondents were also asked to rate the degree of difficulty they experienced in meeting the overall identified undergraduate pediatric nursing curriculum and clinical objectives for students enrolled in their programs. More than 61% of faculty reported that they had difficulty (very to somewhat difficult) in meeting the pediatric nursing learning objectives identified for their students, with only 10% of faculty reporting that it was very easy to meet all pediatric nursing learning objectives. Although the majority of respondents reported that it was difficult meeting learning objectives, the majority
(88%) of faculty also reported that they perceived their graduates' ability to provide nursing care for children, adolescents and families as excellent or good. Programs that report that it is easier to meet pediatric nursing objectives tended to perceive that their graduates are better prepared to provide pediatric nursing care. Those who thought that graduates were poorly or fairly prepared perceived that it was very difficult or somewhat difficult to meet program objectives (P = b .001). Perception of how well graduates are prepared was positively associated with affiliation with Academic Medical Centers. For those who reported that it was very easy or somewhat easy to meet pediatric nursing objectives, the number of clinical hours was greater as compared with those who indicated that it was very or somewhat difficult (P = .024) and that the number of students was greater (mean = 357 vs. 290, P = .033).
Barriers Respondents were asked to indicate the extent to which 13 potential barriers affected the development and delivery of pediatric nursing content in their undergraduate nursing program (Table 4). The five barriers that were most commonly identified as moderate or significant barriers were (a) competition with other programs for clinical practice sites (76%), (b) inadequate number of nurse preceptors (49%), (c) lack of quality clinical sites (48%), (d) lack of direct care/hands-on clinical learning opportunities with children (45%), and (e) limited medication administration and safety experiences (37%). Further analyses of barriers noted insufficient full-time qualified faculty varied by geographic region, with 42% of programs in the southeast, 25% in the midwest, 21% of programs in the northeast, and 11% in the west (χ 2 = 16.86, P = .001) reporting that this was a moderate or significant barrier. A nursing curriculum that was “overloaded” was a moderate or significant barrier for 40% of privately funded programs compared with 28% of
Table 4. Extent to Which Potential Barriers are Encountered in the Management and Delivery of Pediatric Nursing Content (N = 305) Potential barrier Competition for clinical practice sites Lack of quality pediatric clinical practice sites Inadequate number of nurse preceptors Lack of direct care/hands-on clinical learning opportunities with children Insufficient number of full-time qualified faculty Insufficient number of part-time qualified faculty Limited learning opportunities related to pediatric medication administration and safety Nursing curriculum is overloaded Nursing curriculum is skewed to focus on other areas Inadequate clinical skills and preparation of nurse preceptors Lack of support from nursing faculty colleagues who do not feel that pediatric content is all that necessary Lack of interest by employers of new graduates to warrant focus on pediatric nursing State board of nursing does not require pediatric content
Not a barrier, %
Somewhat a barrier, %
Moderate barrier, %
Significant barrier, %
7.8 26.5 23.9 28.8
16.7 25.5 27.1 26.5
19.6 19.6 24.8 21.2
55.9 28.4 24.2 23.5
36.3 35.0 35.6
31.0 30.4 27.8
16.0 19.0 22.2
16.7 15.7 14.4
35.0 51.0 54.2 65.0
31.0 19.0 28.4 21.6
19.6 16.7 13.1 9.5
14.4 13.4 4.2 3.9
63.4
24.8
8.5
3.3
92.8
4.2
2.0
1.0
ISSUES, CHALLENGES AND RECOMMENDATIONS
publicly funded programs (χ 2 = 5.46, P = .019). The ability to provide pediatric medication administration and safety learning opportunities was a moderate or significant barrier for 40% of programs not part of an academic health center compared with 23% of programs not part of an academic health center (χ 2 = 6.91, P = .009). Respondents from programs with more faculty with graduate specialization in pediatrics tended to perceive a greater barrier in terms of insufficient number of full-time qualified faculty (rs = .12, P = .044) and an insufficient number of part-time qualified faculty (rs = .12, P = .045) and less barrier in terms of lack of quality pediatric clinical practice sites (rs = − .13, P = .02). Competition for practice sites was a moderate or significant barrier for small and medium-sized programs (χ 2 = 8.97, P = .03), rural and suburban programs (χ 2 = 8.73, P = .013), programs not part of an academic health center (χ 2 = 10.29, P = .001), and programs offering campus-only education (χ 2 = 4.05, P = .044). Similarly, lack of quality clinical sites was a moderate or significant barrier for smaller programs (χ 2 = 8.95, P = .030), located in rural or suburban areas (χ 2 = 12.68, P = .002), not part of a university an academic health center (χ 2 = 11.06, P = .001) and programs delivered on campus only (χ 2 = 4.38, P = .036).
Discussion The results of this study indicate a number of significant challenges for pediatric education in the undergraduate curriculum. The current content of pediatric nursing didactic courses suggests an emphasis on acute care with limited content in significant, emerging areas such as pediatric genetics and child and adolescent nutrition. Clinical pediatric sites continue to focus on acute care pediatric experiences, often with intense competition for these sites among nursing programs. Recruiting qualified pediatric faculty, both full and part time, is also difficult for many programs. Difficulty in recruiting pediatric faculty is not surprising in this time of faculty shortage (AACN, 2012a, 2012b). Colleges of nursing may find it difficult to match the salaries nurses with pediatric expertise command in clinical settings. The decrease in the number of MSN programs in pediatrics may also have a ripple effect, first with a decrease in the number of nurses with expertise in both pediatric acute care and community health nursing and then with a decrease in the number of individuals with the experience and education needed to teach pediatric nursing to the next generation of nurses. Interestingly, participants in this survey who had more faculty with a master's degree or higher and recent pediatric clinical experience perceived the lack of experienced pediatric faculty and the lack of quality pediatric clinical sites as greater barriers. The curricula findings from this survey should be considered in light of the current changes in the health issues confronting children and adolescents. Survey results indicated limited classroom emphasis on content areas that are currently central to the health of children
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today (e.g., behavior/mental health, nutrition, environmental issues, genomics/genetics). Over the past several years, childhood obesity has increased at an alarming rate with approximately 17% of all children and adolescents in the United States considered obese—triple the rate noted in the past generation (Bloom, Cohen, & Freeman, 2011). More than 5 million children have been diagnosed with attention deficit hyperactivity disorder; almost 5 million children ages 3 to 17 have a learning disability (Child & Adolescent Health Measurement Initiative, 2012) and recent Centers for Disease Control and Prevention (2012) data note that 1 in 88 children in the United States have been identified as having an autism spectrum disorder. In addition, more than 18% of the 74.5 million children in the United States have been diagnosed with a chronic illness (Boyse, Boujaoude, & Laundy, 2008) with more than 10 million children in 2010 experiencing a health problem requiring prescription medication for at least 3 months (Bloom et al., 2011). Without changes in curriculum, the current inadequate didactic content will limit opportunities for nursing care to positively impact the care of children with problems such as obesity, chronic illness, and behavioral mental health concerns. Survey results also revealed a skewed focus on acute care/hospital-based clinical sites as the primary locations for clinical teaching. Because inpatient pediatric census has decreased over the past 10 years (Maguire, 2007), survey data supported the frustrations reported by faculty in competing for and securing acute care clinic sites for student learning. However, preventive care is the most common reason for pediatric office visits (Schor, 2007) with well-child care now constituting 20% to 25% of pediatric office visits overall, including a much greater proportion of visits for children younger than 2 years old. Children spend a significant portion of their day in schools and in community child care, and health care services are increasingly occurring in these settings. Going forward, primary clinical sites for undergraduate pediatric experiences should transition from a focus on inpatient acute care settings to include care for children in their homes, schools, and communities. The risk of continued clinical emphasis on acute care and hospitalbased clinical teaching will divert needed attention to designing clinical experiences that appropriately align nursing education with the emerging health needs of children and families. Although there may be local or state policies that must be addressed, undergraduate programs should renew efforts to expand clinical learning opportunities for students to community child care and school settings. In addition to challenges in recruiting faculty and competing for clinical sites, survey participants noted that identification of pediatric nurse preceptors was difficult. However, school nurses and public health nurses, who typically have broad expertise in the care of children, remain a potential resource as clinical preceptors and may not be utilized adequately. Indeed, school and community child care settings can provide
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rich experiences including opportunities for medication administration and monitoring child safety, two areas that participants reported having difficulty providing to students in their clinical experiences within complex acute care settings. Although survey data were broad and comprehensive, several limitations of this study were identified. The degree of knowledge of the person responding to the survey was important and may have been responsible for those who did not complete the survey. The large range of student enrollment may have been a function of schools that include all 4 years of students, whereas others only included upper division students; the survey did not ask them to specify. Registered nurses (RNs) enrolled in BSN completion programs may have inadvertently been included in student counts, although faculty were asked not to include this group of students. A question designed to report the number of undergraduate faculty with pediatric teaching responsibilities included a check-off box that allowed respondents to select a 5 + faculty option. This query limited analysis and affected the ability of this survey to accurately report the total number of all undergraduate faculty with classroom and/or clinical pediatric nursing teaching responsibilities.
Recommendations Participants at the 2011 IPN Forum reviewed the survey's results and proposed initial educational recommendations. These recommendations were made recognizing that BSN education is for the nurse generalist and should include content and experiences appropriate for the needs of all BSN-prepared RNs. Participants supported the Institute of Medicine (2011) Future of Nursing Report recommendation for a residency program for novice nurses and felt that this was particularly advisable for unique settings such as a hospital-based pediatric unit or a school setting. Forum attendees also recognized that the health challenges for children are changing and that “children are in their communities, particularly homes and schools” (Scholle, Sampsel, Davis, & Schor, 2009). As a result, discussions centered on targeting nursing education opportunities where children and adolescents “live, learn and play.” IPN participants identified five curriculum categories and proposed critical content topics within each of the five categories (Table 5). These recommendations reflect a decreased emphasis on assessment and management of children in the acute care setting and an increase emphasis on caring for children within their families and in their communities. The care of children begins with a solid foundational knowledge of the principles of growth and development. When caring for children, it is critical to recognize that their care is nested in a family, with a range of composition of family membership, cultural values and practices, and unique communication and parenting styles. Families are part of a larger community and society, with factors such as environmental exposures and economic stability impacting the child. For children, common health concerns, such as asthma,
Table 5. Recommended Pediatric Curriculum Categories and Content Topics to Strengthen Undergraduate Pediatric Nursing Education Category
Content
1. Growth and development
2. Family
3. Social determinants
4. Physiology—pathophysiology and pharmacology 5. Prevention and safety
Biopsychosocial Genetic Cognitive development Life style Nutrition Activity Stress and coping Communication Culture/Diversity Parenting Advocacy Economics Environment Congenital Chronic Acute Risk assessment and behavior Health promotion Injury prevention
obesity, and behavioral problems, should be understood, with an emphasis on prevention strategies and management within the family and in the community. The final category identified by the IPN Forum participants was the need to place more emphasis on safety, with increased content on risk reduction and injury prevention. Both environmental and behavioral risk factors continue to compound health threats to children and adolescents. Emerging evidence has also noted the potential increase in risk-taking behaviors among children and adolescents with behavioral health and learning disabilities (McNamara, Vervaeke, & Willoughby, 2008). A renewed curriculum focus on these important issues would strengthen nursing preparation to assist children and families to meet these health challenges.
Conclusion Survey results confirmed a number of challenges confronted by undergraduate programs in the delivery of quality pediatric nursing curriculum. Programs with high difficulty recruiting faculty reported the lack of qualified faculty as a significant barrier to implementing the pediatric curriculum. Continued focus on clinical learning in inpatient pediatric units has also produced significant challenges with programs experiencing high difficulty, with faculty recruitment also reporting competition with other programs for clinical practice sites. While environmental, behavioral, family and chronic illness challenges have become paramount issues in children's health, undergraduate programs have continued to focus on acute, specialty and critical care pediatric content. This mismatch may compromise the ability of nursing programs to produce graduates who understand and can assist in the management of the broader health issues experienced by children and adolescents today.
ISSUES, CHALLENGES AND RECOMMENDATIONS
The role of nursing should continue to focus on assisting children to achieve a healthy, happy, and productive adulthood. To achieve this goal, many health care experts have begun to focus on the concept of an individual's “life course” rather than their “life-span.” There is growing evidence that adverse health, behavioral, learning, and socioeconomic events experienced in childhood contribute to the subsequent development of disease and disability in adulthood. Indeed, childhood obesity is linked to multiple chronic illnesses manifested in adulthood, and behavioral problems in childhood are linked to increased risk for associated morbidities in adulthood. If nurses are to partner with other health care providers to achieve national health goals emphasizing illness prevention rather than sick care, we must begin to review the way we have structured nursing education and clinical experiences (Siegel et al., 2011). It is time to incorporate into BSN programs new models of health that recognize the contributions of early life biopsychosocial experiences on an individual's life course. These models include adverse childhood events (Felitti et al., 1998), the life course health development framework (Halfon & Hochstein, 2002), and the American Academy of Pediatric's Ecobiodevelopmental Framework (Shonkoff & Garner, 2012). With this new direction, nursing students could apply the pathophysiology of stress and illness across an individual's life and expand health promotion and disease prevention strategies and policies beyond their application in adult health nursing courses. Refocusing the nursing curricula to incorporate an understanding of life course events and their application to physical, mental, and social health will help renew opportunities to extend clinical learning experiences for nurses beyond the acute care facility. Of particular importance is the need and opportunity for nursing students to actively advocate for policies and programs that decrease the occurrence of adverse life events such as poverty, abuse, and depravation while also limiting the impact of these events on the individual's health. Because clinical experiences in child health transition to home visits for newborns, community settings, and schools, in addition to acute care settings, BSN students will have the opportunity to develop both health promotion and disease prevention expertise as well as policy and advocacy skills. As participants in the IPN's Forum discussed these challenges, a model for addressing these needs emerged. In 2010, the AACN embarked on a national review of geriatric content in undergraduate education. To address challenges identified in this national review, the AACN with support from the Hartford Foundation led the development of national geriatric competencies and curricular guidelines for undergraduate nursing programs (AACN, 2010). The AACN also spearheaded efforts to develop on-line communities for faculty to share lesson plans, case studies, and best practices. This model has helped undergraduate program faculty strengthen geriatric nursing content in undergraduate education and better prepare graduates to meet the emerging needs of older adults. As the results of
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the IPN's research are shared among pediatric nursing organizations and leaders, we hope that a similar model will develop to assist nursing educators to strengthen undergraduate education. All BSN-prepared nurses need to understand the life course model of health and from these nurses will emerge those who will be our pediatric nursing workforce for the future.
Acknowledgments The authors acknowledge the contributions of members of the 2011 IPN Board of Directors—Sandi Delack, Deborah Etchenkamp, Janis Smith, and Arlene Sperhac as well as contributions from Joan Stanley, senior director of education policy at the AACN. Funding support for this research was provided by the IPN, a foundation of the Pediatric Nursing Certification Board.
References American Association of Colleges of Nursing. (AACN). (2012). 2011-2012 Enrollment and graduation in baccalaureate and graduate programs in nursing. Retrieved from https://apps. aacn.nche.edu/Registration/poSelectPubs.asp. American Association of Colleges of Nursing (AACN). (2012). Nursing faculty shortage. Retrieved from http://www.aacn.nche. edu/media-relations/fact-sheets/nursing-faculty-shortage. American Association of Colleges of Nursing. (AACN). (2010). Recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults. Retrieved from http://www.aacn.nche.edu/geriatric-nursing/competencies. American Association of Colleges of Nursing. (AACN). (2008). The essentials of baccalaureate education for professional nursing practice and took kit. Retrieved from http://www.aacn. nche.edu/publications/order-form/baccalaureate-essentials. Bloom, B., Cohen, R. A., & Freeman, G. (2011). Summary health statistics for U.S. children: National health interview survey 2010. National Center for Health Statistics, 10, Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_250.pdf. Boyse, K., Boujaoude, L., & Laundy, J. (2008). Children with chronic conditions. University of Michigan Health Systems: YourChild Development & Behavior Resources. Retrieved from http://www.med.umich.edu/yourchild/topics/chronic.htm. Child and Adolescent Health Measurement Initiative (CAHMI). (2012). Data resource center for child and adolescent health. U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved from http://www. childhealthdata.org/home. Centers for Disease Control and Prevention. (CDC). (2012). Autism spectrum disorders (ASDs). Retrieved from www.cdc. gov/autism. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258. Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health, policy, and research. The Millbank Quarterly, 80, 433–479. Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
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Maguire, P. (October, 2007). Getting squeezed: Emerging trends in pediatric inpatient services. Today’s Hospitalist. Retrieved from http://www.todayshospitalist.com/index.php? b=articles_read&cnt=441. McNamara, J., Vervaeke, S. L., & Willoughby, T. (2008). Learning disabilities and risk-taking behavior in adolescents: A comparison of those with and without comorbid attentiondeficit/hyperactivity disorder. Journal of Learning Disabilities, 41, 561–574, http://dx.doi.org/10.1177/0022219408326096. Scholle, S. H., Sampsel, S. L., Davis, N. E. P., & Schor, E. L. (2009). Quality of child health care: Expanding the scope and flexibility of measurement approaches. The Commonwealth Fund pub. 1276, 54.
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Schor, E. L. (2007). The future pediatrician: Promoting children's health and development. The Journal of Pediatrics, 151, (5 suppl), S11–S16, http://dx.doi.org/10.1016/j.jpeds.2007.08.014. Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S., McGuinn, L., Pascoe, J., & Wood, D. L. (2011). The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129:e232. Shonkoff, J. P. & Garner, A. S. (2012). The Committee On Psychosocial Aspects Of Child And Family Health, Committee On Early Childhood, Adoption, And Dependent Care: Section On Developmental And Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, e232–e246.
AND
JANET S. WYATT, PHD, RN, FAANP†
The topic is a national review of content and clinical experiences in undergraduate pediatric nursing education with recommendations for strengthening the pediatric nursing curriculum. American Association of Colleges of Nursing member programs (N = 596) were surveyed with 344 schools responding. A 39-item survey collected school demographics, faculty characteristics, pediatric classroom and clinical information, and actual and perceived barriers to implementing the pediatric curriculum. Recommendations for change were offered by participants attending the 2011 Institute of Pediatric Nursing Nursing Forum. A mean of 33 (SD = 27) total undergraduate faculty included an average of 3.1 (SD = 3.11) faculty with graduate specialization and/or recent clinical experience in pediatrics. Within a mean of 43 (range = 0–136 hours) pediatric classroom hours, more than 59% of programs reported 2 hours or less in pediatric genetics, environmental health, and child nutrition. Content focused on acute and specialty care with programs using pediatric inpatient medical (68%) and surgical units (40%) for clinical learning. Recruiting pediatric faculty was a common issue and reported as extremely (23%) to moderately difficult (26%). Competition for clinical practice sites (76%) was a reported barrier. Adjustments in the pediatric undergraduate curriculum are recommended to highlight current health issues experienced by children including expansion of clinical learning experiences to settings where children live, learn, and play. (Index words: Pediatric nursing education; Institute of Pediatric Nursing) J Prof Nurs 30:130–138, 2014. © 2014 Published by Elsevier Inc.
F
OR THE PAST 3 years, the Institute of Pediatric Nursing (IPN) (www.ipedsnursing.org) has assembled 50 leaders from more than 15 national pediatric nursing organizations and 10 major children's hospitals at an annual, invitational forum. As a nonprofit “organization of organizations,” the IPN serves as the collective voice for pediatric nursing, developing activities and initiatives in support of pediatric nursing and the health care needs of children and their families. In 2010, participants at the IPN Pediatric Nursing Forum (forum) identified that the depth and breadth of pediatric nursing content in undergraduate nursing education was a significant concern for pediatric nursing leaders in education and practice. With limited exposure to care of ∗President, Institute of Pediatric Nursing and Associate Dean for Research, The University of Iowa College of Nursing, Round Hill, VA. †Consultant, Institute of Pediatric Nursing, Round Hill, VA. Address correspondence to Dr. Wyatt: Consultant, Institute of Pediatric Nursing, 35460 Sassafras Drive, Round Hill, VA 20141. E-mail: jwyatt@ ipedsnursing.org 8755-7223/13/$ - see front matter 130 http://dx.doi.org/10.1016/j.profnurs.2013.07.003
children during their undergraduate education, new graduates may be less likely to enter jobs focused on children, impacting the development of future pediatric nurses and leaders. As a sign of decreasing interest in pediatric nursing, recent national data has documented a growing national decline in enrollment in graduate advanced practice pediatric nursing programs (American Association of Colleges of Nursing [AACN], 2012a, 2012b). In addition, nursing leadership from children's hospitals across the country have discussed difficulties recruiting expert pediatric nurses with the knowledge and skills needed to assist children and families with the growing burden of chronic illness and emerging complex behavioral health issues. Additional discussion at the forum suggested several areas of potential concern. Nursing educators have reported difficulty in recruiting and retaining pediatric nursing faculty, decreased curricular content focused on children and families, and challenges identifying appropriate pediatric clinical placements for undergraduates. Children with acute health care problems now spend
Journal of Professional Nursing, Vol 30, No. 2 (March/April), 2014: pp 130–138 © 2014 Published by Elsevier Inc.
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less time in acute care settings, decreasing availability of clinical practicum sites. However, a lack of data on current pediatric content in undergraduate curriculums and clinical practices was identified. To address this knowledge gap and to assure a pediatric nursing workforce in the future, IPN leadership targeted their efforts in 2011 on clarifying the current state of pediatric nursing in undergraduate bachelor of science in nursing (BSN) programs and working together with IPN participants to review findings and propose recommendations to strengthen pediatric nursing education. The purpose of this article is to describe the results of a national survey to identify the current trends and challenges in providing pediatric nursing education in baccalaureate (BSN) nursing programs and to utilize these findings to propose recommendations to strengthen undergraduate pediatric nursing education. The study was designed as a partnership between the AACN and the IPN. Specific objectives of the study were to describe (a) the characteristics of the schools/colleges and the faculty currently teaching the didactic and clinical pediatric content, including challenges in recruiting faculty, (b) the didactic content and clinical experiences in the pediatric curriculum, including use of alternative teaching strategies, and (c) barriers encountered in providing pediatric content in AACN member BSN programs. An initial goal of this research was to incorporate the information obtained in this survey together with the expertise of pediatric nurse leaders within the IPN to provide creative guidance to baccalaureate nursing programs to strengthen delivery of content related to nursing care of the pediatric population. As undergraduate nursing education programs establish the AACN's Baccalaureate Essentials (AACN, 2008) as the framework and structure for undergraduate nursing education, development of vital undergraduate pediatric nursing resources will provide the means necessary for faculty to assure quality undergraduate pediatric nursing education.
completed the entire survey. More than 81% of faculty (247) completing the survey reported that they had pediatric nursing teaching responsibilities. Analysis of responses from those completing the survey and those who did not complete the survey revealed that those who fully completed the survey came from programs with more faculty with recent clinical pediatric clinical experience (3.2 vs. 2.1, t = 2.19, P = .03) who also had stand-alone pediatric nursing courses (51% vs. 35%, χ 2 = 6.29, P = .04).
Methods
Data Management and Analysis
Sample
Analyses were completed using descriptive statistics appropriate for the type of data. Frequency and crosstabs were used for categorical data, and means, standard deviations, medians, and ranges were used for continuous data. For group comparisons, chi-squared test, t tests and analysis of variance were used as needed. Correlations and regression were used to further explore relationships and explanatory factors.
The collegiate AACN member e-mail list of undergraduate nursing programs (N = 596) provided the sample for this descriptive survey research. Four hundred sixty responses were downloaded from the SurveyMonkey© platform that hosted the survey. Based on city, state, IP address, financial support, location, and type of program, multiple responses from within the same school were identified with the most recent entry retained. Removal of duplicate responses resulted in three hundred ninety-four (66% of the schools) responses from schools. Fifty schools were eliminated from the analysis because they either did not indicate more than 10 students (n = 4) or did not complete the first 14 demographic questions (n = 46). The final sample prepared for data analysis consisted of responses from 344 schools or 58% of the AACN member schools. Not all items were completed by all respondents. Of the 344 schools, 275 (88%)
Measure The survey was developed with national input from senior pediatric nursing educators and included input from the IPN Board of Directors and the senior director of education policy at the AACN. As the survey was developed, using the on-line SurveyMonkey format, it was reviewed by the IPN Board and additional pediatric nursing faculty experts and revised accordingly. The final version of the survey consisted of 39 questions, which included a combination of closed and open-ended questions. The survey was divided into five sections covering demographic items that provided a description of the college/school of nursing, the faculty, didactic curriculum content, clinical experiences, and perceived barriers to implementation of undergraduate program pediatric learning objectives.
Procedures E-mails inviting participation in this research were sent to the 596 undergraduate program directors or deans included in the AACN membership database. Participation in the survey was open for approximately 1 month (August 18 to September 16, 2011). Deans and program directors were asked to forward the survey to the lead faculty member responsible for managing delivery of pediatric nursing content in the undergraduate program. Two e-mail reminders were sent to all undergraduate program directors during this period.
Results Colleges/Schools The description of the participating schools is summarized in Table 1. The geographic distribution of schools responding to the survey was similar to the distribution of AACN member schools, although there were 6% less responding from the southeast and 10% more from the midwest. The majority of responding schools were not part of an academic health care center (77%), offered
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Table 1. Characteristics of Responding Schools Characteristics (n = 344)
Number (%)
Geographic region Northeast 62 (18.0) Southeast 103 (29.9) Midwest 140 (40.7) West 38 (11.0) University health care consortium or academic health center No 266 (77.3) Yes 78 (22.7) Financial support Private (nonreligious) 87 (25.3) Public 173 (50.3) Religious 84 (24.4) Location Rural 66 (19.2) Suburban 103 (29.9) Urban 175 (50.9) Type of program Undergraduate and graduate 249 (72.4) Undergraduate only 95 (27.6) Size of PROGRAM Small: ≤ 150 students 91 (26.5) Medium: 151–300 students 123 (35.8) Large: 301–500 students 76 (22.1) Very Large: 501 + students 54 (15.7)
both graduate and undergraduate education (72%), and were in urban areas (51%). Financial support of the schools was evenly divided between public (50%) and private (25% religious and 25% nonreligious). The size of the programs was based on the number of full- and parttime students in the undergraduate nursing program. The range was large, with the programs reporting between 11 and 2,500 students (X = 312.5; SD = 257.9). To facilitate data analysis, we divided the programs into four size categories (small, medium, large, and very large).
Faculty Participants reported a wide range of the number of faculty at their schools, with a combined number of fulland part-time faculty ranging from 0 to 200 with a mean of 33 (SD = 27). The reported undergraduate nursing faculty to student ratio ranged from 1:1 to 1:70 with a mean of 1:12 and a median of 1:10. Survey results noted that faculty teaching at schools with only undergraduate programs had smaller faculty-to-student ratios. Data were collected to describe the number of faculty with graduate pediatric specialty preparation (master's degree and higher) and faculty reporting recent pediatric nursing clinical (nonteaching) experience. The average number of faculty with a master's degree or higher with a specialization in pediatrics was 3.1 (SD = 3.11) with a median of two pediatric faculty per school. Similarly, the average number of faculty (with or without graduate specialty preparation) reporting recent (past 2 years) pediatric nursing clinical experience not including student supervision was 3.1 (SD = 2.91) with a median of two faculty per school. Programs were also asked to
respond to a three-part question designed to determine the total number of undergraduate faculty with pediatric teaching responsibilities for classroom only (a), clinical only (b), and combined classroom and clinical (b) teaching responsibilities. More than a third of participants (107) selected the option “5 + faculty” to describe the number of faculty with teaching assignments in each of these three areas. These responses suggest that undergraduate programs consistently employ additional, nonpediatric specialty faculty to teach undergraduate pediatric classroom and clinical content. When assessing interactions, very large schools in the northeast with both graduate and undergraduate programs and programs that were part of academic health centers (AHC) tended to have twice as many faculty with Masters of Science in Nursing (MSN) degrees or higher in pediatrics and faculty with recent pediatric clinical experience than small, non-AHC, undergraduate-only programs and programs in the southeast. Data describing the distribution of faculty with graduate pediatric specialization and/or faculty with recent (nonteaching) pediatric clinical experience are profiled in Table 2. In order to better understand faculty issues, respondents were asked to report their experiences related to recruitment of qualified pediatric faculty. Only 26% of the schools reported no difficulties with recruiting qualified pediatric nursing faculty; more than half (52%) reported extreme or moderate difficulty. No associations were found between difficulty with recruiting faculty and geographic region, location, size of program, financial support, type of program, or affiliation with AHC. An open-ended question allowed responders to provide additional comments to provide a better understanding of the issues associated with recruiting pediatric faculty. Half of the participants responded to this question. Qualitative analysis of these responses revealed three major issues and included difficulty finding qualified part-time and full-time pediatric nursing faculty (44%), low salary and competition with clinical salaries (18%), and needing to hire and train their own nursing graduates to fill pediatric teaching needs and develop creative arrangements with hospitals with pediatric inpatient units, including children's hospitals (5%).
Curriculum The total number of pediatric nursing didactic class hours ranged from 0 to 136 hours with an average of 43 hours. Pediatric didactic courses were primarily offered as an oncampus option only (81%) versus courses offered both on campus and Web-based/distance learning (19%). Programs primarily had stand-alone pediatric nursing courses (49%), with fewer describing integrated courses (31%) or both (20%). A list of 11 broad pediatric nursing curriculum content areas was developed, and faculty were asked to report the number of classroom hours within the entire undergraduate curriculum that were devoted to these topics. Table 3 summarizes the number of classroom hours and specific content covered in the didactic
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Table 2. Number of Pediatric Nursing Faculty in Undergraduate Nursing Programs Faculty with graduate degree in pediatrics and faculty with recent (within 2 years) pediatric clinical experience by size of program, geographic region, type of program, and academic health center Master's or higher degree with graduate specialization in pediatrics
Recent pediatric nursing clinical (nonteaching) practice experience
Mean (SD)
Mean (SD)
2.0 (2.14) 3.0 (2.61) 3.6 (3.07) 4.9 (4.49) F = 11.47, P b .001
2.0 (1.97) 2.8 (2.33) 3.7 (2.81) 4.6 (4.37) F = 12.06, P b .001
4.4 (4.50) 2.8 (2.49) 2.7 (2.41) 3.4 (3.47) F = 5.10, P = .002
4.4 (4.18) 2.8 (2.47) 2.6 (2.30) 3.3 (2.99) F = 5.85, P = .001
3.8 (3.39) 1.5 (1.18) t = 9.07, P b .001
3.5 (3.13) 1.9 (1.77) t = 4.76, P b .001
2.7 (2.31) 4.8 (4.63) t = 5.42, P b .001
2.7 (2.22) 4.4 (4.28) t = 4.89, P b .001
Size of program Small Medium Large Very large Geographic region Northeast Southeast Midwest West Type of program Undergraduate and graduate Undergraduate only Academic health center No Yes
pediatric courses and any other pediatric nursing content delivered in other courses within the undergraduate curriculum. More than 59% of programs reported 2 hours or less class time within the entire undergraduate curriculum in each of the following content areas: pediatric genetics, environmental health, and child and adolescent nutrition. More than 47% of programs reported 2 hours or less of pediatric content in pediatric behavioral/mental health, family health/ parenting, and community/school health. The most frequently included content areas were acute care, with 47% reporting more than 11 hours in their curriculum, and chronic illness/specialty care, with 33% reporting 11 or more hours. When asked what other courses, such as health assessment, community health and psych/mental health courses, might include
pediatric content, 25% of the programs indicated that either they did not have these courses or there was no pediatric content hours in these courses. Only 42 programs (12%) offer an elective pediatric nursing course. The total number of reported pediatric clinical hours ranged from 0 to 225 hours with a mean of 83, median of 116, and mode of 90. Schools were asked to select the clinical placement sites that they most commonly used from a comprehensive list of 16 different pediatricfocused clinic settings ranging from newborn care to schools, mental health clinics and hospitals, and emergency care settings. The most frequently used pediatric clinical sites were (a) pediatric inpatient medical units (68%), (b) pediatric inpatient surgical units (40%), (c) pediatric specialty care units (19%), (d)
Table 3. Total Curriculum Classroom Hours by Pediatric Nursing Undergraduate Content (N = 315) Number of hours (largest percent of content in bold) Content and topics (alphabetical)
None, %
1–2, %
3–4, %
5–6, %
7–8, %
9–10, %
11–12, %
13 +, %
Child/Adolescent behavioral/Mental health Child/Adolescent growth and development Child/Adolescent nutrition Community and school health Family health and parenting Health promotion/Well child care Pediatric acute care Pediatric chronic illness/Specialty care Pediatric critical care/Emergency care Pediatric environmental health Pediatric genetics
6.7 1.0 2.9 9.2 5.4 1.0 0.6 1.0 4.8 5.4 7.9
41.0 18.4 56.5 38.1 42.9 15.6 6.7 11.1 32.4 57.8 67.3
29.2 32.1 27.3 26.3 27.3 29.5 11.7 17.1 30.2 23.2 18.7
11.7 21.6 7.0 10.5 12.7 22.5 11.7 17.5 12.1 7.9 2.5
5.7 7.6 3.5 7.3 5.1 12.7 11.1 9.8 6.7 3.8 1.6
1.9 5.7 2.5 2.2 1.6 7.0 10.8 10.5 5.1 1.3 0.6
1.9 4.8 0 1.9 1.6 4.8 13.7 12.4 3.8 0.3 0.3
1.9 8.9 0.3 14.4 3.5 7.0 33.7 20.6 5.1 0.3 1.0
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pediatric intensive care units (10%), and (e) elementary schools (10%). Programs also reported their experiences (within the past 2 academic years) in securing pediatric clinical practice sites. It was extremely difficult for 24% of the schools, moderately difficult for 29%, somewhat difficult for 32%, and not difficult for 16%.The only statistically significant factor associated with difficulty finding clinical sites was with difficulty in recruiting qualified pediatric faculty (P b .001). If schools indicated that it was extremely/moderately difficult to find clinical placements, 67% also identified that it was extremely/ moderately difficult to recruit qualified faculty. Respondents were also asked to report the range of resources and alternative teaching strategies used to supplement or support classroom lectures and clinical experiences. In the didactic course, pediatric case studies (82%) and multimedia strategies (61%) were moderately or highly used, whereas in the clinical sites, pediatric case studies (58%) and mannequin models (58%) were moderately or highly used. Mannequin models were infrequently used in the classroom by 72% of the programs. Other strategies that were infrequently used or were not used at all either in the classroom or in clinical sites include podcast independent learning (class, 93%; clinical, 97%), multidisciplinary learning (class, 67%; clinical, 88%), and self-directed learning (class, 53%; clinical, 63%). Respondents were also asked to rate the degree of difficulty they experienced in meeting the overall identified undergraduate pediatric nursing curriculum and clinical objectives for students enrolled in their programs. More than 61% of faculty reported that they had difficulty (very to somewhat difficult) in meeting the pediatric nursing learning objectives identified for their students, with only 10% of faculty reporting that it was very easy to meet all pediatric nursing learning objectives. Although the majority of respondents reported that it was difficult meeting learning objectives, the majority
(88%) of faculty also reported that they perceived their graduates' ability to provide nursing care for children, adolescents and families as excellent or good. Programs that report that it is easier to meet pediatric nursing objectives tended to perceive that their graduates are better prepared to provide pediatric nursing care. Those who thought that graduates were poorly or fairly prepared perceived that it was very difficult or somewhat difficult to meet program objectives (P = b .001). Perception of how well graduates are prepared was positively associated with affiliation with Academic Medical Centers. For those who reported that it was very easy or somewhat easy to meet pediatric nursing objectives, the number of clinical hours was greater as compared with those who indicated that it was very or somewhat difficult (P = .024) and that the number of students was greater (mean = 357 vs. 290, P = .033).
Barriers Respondents were asked to indicate the extent to which 13 potential barriers affected the development and delivery of pediatric nursing content in their undergraduate nursing program (Table 4). The five barriers that were most commonly identified as moderate or significant barriers were (a) competition with other programs for clinical practice sites (76%), (b) inadequate number of nurse preceptors (49%), (c) lack of quality clinical sites (48%), (d) lack of direct care/hands-on clinical learning opportunities with children (45%), and (e) limited medication administration and safety experiences (37%). Further analyses of barriers noted insufficient full-time qualified faculty varied by geographic region, with 42% of programs in the southeast, 25% in the midwest, 21% of programs in the northeast, and 11% in the west (χ 2 = 16.86, P = .001) reporting that this was a moderate or significant barrier. A nursing curriculum that was “overloaded” was a moderate or significant barrier for 40% of privately funded programs compared with 28% of
Table 4. Extent to Which Potential Barriers are Encountered in the Management and Delivery of Pediatric Nursing Content (N = 305) Potential barrier Competition for clinical practice sites Lack of quality pediatric clinical practice sites Inadequate number of nurse preceptors Lack of direct care/hands-on clinical learning opportunities with children Insufficient number of full-time qualified faculty Insufficient number of part-time qualified faculty Limited learning opportunities related to pediatric medication administration and safety Nursing curriculum is overloaded Nursing curriculum is skewed to focus on other areas Inadequate clinical skills and preparation of nurse preceptors Lack of support from nursing faculty colleagues who do not feel that pediatric content is all that necessary Lack of interest by employers of new graduates to warrant focus on pediatric nursing State board of nursing does not require pediatric content
Not a barrier, %
Somewhat a barrier, %
Moderate barrier, %
Significant barrier, %
7.8 26.5 23.9 28.8
16.7 25.5 27.1 26.5
19.6 19.6 24.8 21.2
55.9 28.4 24.2 23.5
36.3 35.0 35.6
31.0 30.4 27.8
16.0 19.0 22.2
16.7 15.7 14.4
35.0 51.0 54.2 65.0
31.0 19.0 28.4 21.6
19.6 16.7 13.1 9.5
14.4 13.4 4.2 3.9
63.4
24.8
8.5
3.3
92.8
4.2
2.0
1.0
ISSUES, CHALLENGES AND RECOMMENDATIONS
publicly funded programs (χ 2 = 5.46, P = .019). The ability to provide pediatric medication administration and safety learning opportunities was a moderate or significant barrier for 40% of programs not part of an academic health center compared with 23% of programs not part of an academic health center (χ 2 = 6.91, P = .009). Respondents from programs with more faculty with graduate specialization in pediatrics tended to perceive a greater barrier in terms of insufficient number of full-time qualified faculty (rs = .12, P = .044) and an insufficient number of part-time qualified faculty (rs = .12, P = .045) and less barrier in terms of lack of quality pediatric clinical practice sites (rs = − .13, P = .02). Competition for practice sites was a moderate or significant barrier for small and medium-sized programs (χ 2 = 8.97, P = .03), rural and suburban programs (χ 2 = 8.73, P = .013), programs not part of an academic health center (χ 2 = 10.29, P = .001), and programs offering campus-only education (χ 2 = 4.05, P = .044). Similarly, lack of quality clinical sites was a moderate or significant barrier for smaller programs (χ 2 = 8.95, P = .030), located in rural or suburban areas (χ 2 = 12.68, P = .002), not part of a university an academic health center (χ 2 = 11.06, P = .001) and programs delivered on campus only (χ 2 = 4.38, P = .036).
Discussion The results of this study indicate a number of significant challenges for pediatric education in the undergraduate curriculum. The current content of pediatric nursing didactic courses suggests an emphasis on acute care with limited content in significant, emerging areas such as pediatric genetics and child and adolescent nutrition. Clinical pediatric sites continue to focus on acute care pediatric experiences, often with intense competition for these sites among nursing programs. Recruiting qualified pediatric faculty, both full and part time, is also difficult for many programs. Difficulty in recruiting pediatric faculty is not surprising in this time of faculty shortage (AACN, 2012a, 2012b). Colleges of nursing may find it difficult to match the salaries nurses with pediatric expertise command in clinical settings. The decrease in the number of MSN programs in pediatrics may also have a ripple effect, first with a decrease in the number of nurses with expertise in both pediatric acute care and community health nursing and then with a decrease in the number of individuals with the experience and education needed to teach pediatric nursing to the next generation of nurses. Interestingly, participants in this survey who had more faculty with a master's degree or higher and recent pediatric clinical experience perceived the lack of experienced pediatric faculty and the lack of quality pediatric clinical sites as greater barriers. The curricula findings from this survey should be considered in light of the current changes in the health issues confronting children and adolescents. Survey results indicated limited classroom emphasis on content areas that are currently central to the health of children
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today (e.g., behavior/mental health, nutrition, environmental issues, genomics/genetics). Over the past several years, childhood obesity has increased at an alarming rate with approximately 17% of all children and adolescents in the United States considered obese—triple the rate noted in the past generation (Bloom, Cohen, & Freeman, 2011). More than 5 million children have been diagnosed with attention deficit hyperactivity disorder; almost 5 million children ages 3 to 17 have a learning disability (Child & Adolescent Health Measurement Initiative, 2012) and recent Centers for Disease Control and Prevention (2012) data note that 1 in 88 children in the United States have been identified as having an autism spectrum disorder. In addition, more than 18% of the 74.5 million children in the United States have been diagnosed with a chronic illness (Boyse, Boujaoude, & Laundy, 2008) with more than 10 million children in 2010 experiencing a health problem requiring prescription medication for at least 3 months (Bloom et al., 2011). Without changes in curriculum, the current inadequate didactic content will limit opportunities for nursing care to positively impact the care of children with problems such as obesity, chronic illness, and behavioral mental health concerns. Survey results also revealed a skewed focus on acute care/hospital-based clinical sites as the primary locations for clinical teaching. Because inpatient pediatric census has decreased over the past 10 years (Maguire, 2007), survey data supported the frustrations reported by faculty in competing for and securing acute care clinic sites for student learning. However, preventive care is the most common reason for pediatric office visits (Schor, 2007) with well-child care now constituting 20% to 25% of pediatric office visits overall, including a much greater proportion of visits for children younger than 2 years old. Children spend a significant portion of their day in schools and in community child care, and health care services are increasingly occurring in these settings. Going forward, primary clinical sites for undergraduate pediatric experiences should transition from a focus on inpatient acute care settings to include care for children in their homes, schools, and communities. The risk of continued clinical emphasis on acute care and hospitalbased clinical teaching will divert needed attention to designing clinical experiences that appropriately align nursing education with the emerging health needs of children and families. Although there may be local or state policies that must be addressed, undergraduate programs should renew efforts to expand clinical learning opportunities for students to community child care and school settings. In addition to challenges in recruiting faculty and competing for clinical sites, survey participants noted that identification of pediatric nurse preceptors was difficult. However, school nurses and public health nurses, who typically have broad expertise in the care of children, remain a potential resource as clinical preceptors and may not be utilized adequately. Indeed, school and community child care settings can provide
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rich experiences including opportunities for medication administration and monitoring child safety, two areas that participants reported having difficulty providing to students in their clinical experiences within complex acute care settings. Although survey data were broad and comprehensive, several limitations of this study were identified. The degree of knowledge of the person responding to the survey was important and may have been responsible for those who did not complete the survey. The large range of student enrollment may have been a function of schools that include all 4 years of students, whereas others only included upper division students; the survey did not ask them to specify. Registered nurses (RNs) enrolled in BSN completion programs may have inadvertently been included in student counts, although faculty were asked not to include this group of students. A question designed to report the number of undergraduate faculty with pediatric teaching responsibilities included a check-off box that allowed respondents to select a 5 + faculty option. This query limited analysis and affected the ability of this survey to accurately report the total number of all undergraduate faculty with classroom and/or clinical pediatric nursing teaching responsibilities.
Recommendations Participants at the 2011 IPN Forum reviewed the survey's results and proposed initial educational recommendations. These recommendations were made recognizing that BSN education is for the nurse generalist and should include content and experiences appropriate for the needs of all BSN-prepared RNs. Participants supported the Institute of Medicine (2011) Future of Nursing Report recommendation for a residency program for novice nurses and felt that this was particularly advisable for unique settings such as a hospital-based pediatric unit or a school setting. Forum attendees also recognized that the health challenges for children are changing and that “children are in their communities, particularly homes and schools” (Scholle, Sampsel, Davis, & Schor, 2009). As a result, discussions centered on targeting nursing education opportunities where children and adolescents “live, learn and play.” IPN participants identified five curriculum categories and proposed critical content topics within each of the five categories (Table 5). These recommendations reflect a decreased emphasis on assessment and management of children in the acute care setting and an increase emphasis on caring for children within their families and in their communities. The care of children begins with a solid foundational knowledge of the principles of growth and development. When caring for children, it is critical to recognize that their care is nested in a family, with a range of composition of family membership, cultural values and practices, and unique communication and parenting styles. Families are part of a larger community and society, with factors such as environmental exposures and economic stability impacting the child. For children, common health concerns, such as asthma,
Table 5. Recommended Pediatric Curriculum Categories and Content Topics to Strengthen Undergraduate Pediatric Nursing Education Category
Content
1. Growth and development
2. Family
3. Social determinants
4. Physiology—pathophysiology and pharmacology 5. Prevention and safety
Biopsychosocial Genetic Cognitive development Life style Nutrition Activity Stress and coping Communication Culture/Diversity Parenting Advocacy Economics Environment Congenital Chronic Acute Risk assessment and behavior Health promotion Injury prevention
obesity, and behavioral problems, should be understood, with an emphasis on prevention strategies and management within the family and in the community. The final category identified by the IPN Forum participants was the need to place more emphasis on safety, with increased content on risk reduction and injury prevention. Both environmental and behavioral risk factors continue to compound health threats to children and adolescents. Emerging evidence has also noted the potential increase in risk-taking behaviors among children and adolescents with behavioral health and learning disabilities (McNamara, Vervaeke, & Willoughby, 2008). A renewed curriculum focus on these important issues would strengthen nursing preparation to assist children and families to meet these health challenges.
Conclusion Survey results confirmed a number of challenges confronted by undergraduate programs in the delivery of quality pediatric nursing curriculum. Programs with high difficulty recruiting faculty reported the lack of qualified faculty as a significant barrier to implementing the pediatric curriculum. Continued focus on clinical learning in inpatient pediatric units has also produced significant challenges with programs experiencing high difficulty, with faculty recruitment also reporting competition with other programs for clinical practice sites. While environmental, behavioral, family and chronic illness challenges have become paramount issues in children's health, undergraduate programs have continued to focus on acute, specialty and critical care pediatric content. This mismatch may compromise the ability of nursing programs to produce graduates who understand and can assist in the management of the broader health issues experienced by children and adolescents today.
ISSUES, CHALLENGES AND RECOMMENDATIONS
The role of nursing should continue to focus on assisting children to achieve a healthy, happy, and productive adulthood. To achieve this goal, many health care experts have begun to focus on the concept of an individual's “life course” rather than their “life-span.” There is growing evidence that adverse health, behavioral, learning, and socioeconomic events experienced in childhood contribute to the subsequent development of disease and disability in adulthood. Indeed, childhood obesity is linked to multiple chronic illnesses manifested in adulthood, and behavioral problems in childhood are linked to increased risk for associated morbidities in adulthood. If nurses are to partner with other health care providers to achieve national health goals emphasizing illness prevention rather than sick care, we must begin to review the way we have structured nursing education and clinical experiences (Siegel et al., 2011). It is time to incorporate into BSN programs new models of health that recognize the contributions of early life biopsychosocial experiences on an individual's life course. These models include adverse childhood events (Felitti et al., 1998), the life course health development framework (Halfon & Hochstein, 2002), and the American Academy of Pediatric's Ecobiodevelopmental Framework (Shonkoff & Garner, 2012). With this new direction, nursing students could apply the pathophysiology of stress and illness across an individual's life and expand health promotion and disease prevention strategies and policies beyond their application in adult health nursing courses. Refocusing the nursing curricula to incorporate an understanding of life course events and their application to physical, mental, and social health will help renew opportunities to extend clinical learning experiences for nurses beyond the acute care facility. Of particular importance is the need and opportunity for nursing students to actively advocate for policies and programs that decrease the occurrence of adverse life events such as poverty, abuse, and depravation while also limiting the impact of these events on the individual's health. Because clinical experiences in child health transition to home visits for newborns, community settings, and schools, in addition to acute care settings, BSN students will have the opportunity to develop both health promotion and disease prevention expertise as well as policy and advocacy skills. As participants in the IPN's Forum discussed these challenges, a model for addressing these needs emerged. In 2010, the AACN embarked on a national review of geriatric content in undergraduate education. To address challenges identified in this national review, the AACN with support from the Hartford Foundation led the development of national geriatric competencies and curricular guidelines for undergraduate nursing programs (AACN, 2010). The AACN also spearheaded efforts to develop on-line communities for faculty to share lesson plans, case studies, and best practices. This model has helped undergraduate program faculty strengthen geriatric nursing content in undergraduate education and better prepare graduates to meet the emerging needs of older adults. As the results of
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the IPN's research are shared among pediatric nursing organizations and leaders, we hope that a similar model will develop to assist nursing educators to strengthen undergraduate education. All BSN-prepared nurses need to understand the life course model of health and from these nurses will emerge those who will be our pediatric nursing workforce for the future.
Acknowledgments The authors acknowledge the contributions of members of the 2011 IPN Board of Directors—Sandi Delack, Deborah Etchenkamp, Janis Smith, and Arlene Sperhac as well as contributions from Joan Stanley, senior director of education policy at the AACN. Funding support for this research was provided by the IPN, a foundation of the Pediatric Nursing Certification Board.
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