SPN NEWS. Column Editor: Dana Etzel-Hardman, MSN, MBA, RN, CPN

SPN NEWS Column Editor: Dana Etzel-Hardman, MSN, MBA, RN, CPN Preparing Pediatric Nurses for the 21st Century: Perceptions of Nurse Managers, Nursing Faculty, and Staff Nurses Donna Miles Curry PhD, RN, PCNS-BC a, *, Zepure Samawi PhD, RN b a College of Nursing and Health, Wright State University, Dayton, OH b School of Nursing, Saint Xavier University, Chicago, IL Background and Literature Review A core curriculum for the nursing care of children and their families was published in 1999 (Broome & Rollins, 1999). This document was based on the Standards and Guidelines for Pre-licensure and Early Professional Education for the Nursing Care of Children and Families, which represented the culmination of a 5-year effort by pediatric academic and clinical educators to draft guidelines for pediatric nursing education. The core curriculum sought to acknowledge the fact that the nature of care and where it is delivered had shifted (pp vii). Pediatric nursing education should be based on three curriculum strands: child, family, and society factors; specific clinical problems or areas; and care delivery. Even 20 years ago, those authors clearly identified a shift in provision of care for children with acute and chronic health problems from hospital to community settings. Pediatric nursing faculty today agree that competently preparing new-graduate nurses to practice in the 21st century is a challenge (Broussard, Myers, & Lemoine, 2009; Lynch, 2007). One main change or challenge may include the integration of pediatric content threaded in the curriculum as suggested by the Essentials of Baccalaureate Education for Professional Nursing Practice (America Association of Colleges of Nursing [AACN], 2008). Challenges also include limitations in clinical opportunities for nursing Corresponding author: Donna Miles Curry, PhD, RN, PCNS-BC. E-mail address: donna.curry@wright.edu (D.M. Curry). students to practice pediatric skills and pediatric faculty shortage (AACN, 2008; Lynch, 2007). Based upon this, the Society of Pediatric Nurses (SPN) Education Committee discussed these changes and challenges and thus developed a survey of pediatric nurse managers and pediatric faculty to identify change in trends of pediatric patients and curricular pediatric issues. The SPN Education Committee sought to identify specific challenges and their salient impact for undergraduate curriculum in particular for pediatric content. Method Design and Instrument This descriptive survey used a questionnaire consisting of 16 questions created by an ad hoc group from the SPN Education Committee consisting of two doctorally prepared pediatric nurse educators with pediatric experience ranging from 20 to 36 years and a hospitalbased pediatric nurse educator. It was reviewed by the entire committee for content validity and readability. In addition to items related to demographics, two specific sets of questions were developed. One set was directed to nurse managers, pediatric nurses, and clinical agency educators and queried the preparedness of new-graduate nurses in pediatrics units, and the other set of questions was directed to pediatric nurse faculty and was related to curricular issues of pediatric content in undergraduate curriculum. 0882-5963/$ see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.09.001

600 SPN News Human Subject Protection Permission to conduct the study was obtained from the institutional review boards (IRBs) at both coinvestigators' universities. Following IRB approval, the researchers asked permission from the SPN Board of Directors to host the survey on their national organization web site. Data Collection The SPN sent an e-mail to over 2,000 members, inviting those members who work as pediatric nurse managers, pediatric staff nurses, and pediatric nursing faculties to participate. The e-mail contained a unique survey link that participants clicked on which connected directly to the survey (Survey Monkey TM ). Completed survey data were stored on a secured infrastructure by Survey Monkey, and only the research team had access to it. At the end of the data collection period, the SPN headquarter staff downloaded and forwarded the data to the coinvestigators, which were analyzed using descriptive statistics or content analysis. Data collection was conducted from July 2010 through December 2010. Sample The convenience sample (N = 175) included 48 staff nurses, 15 charge nurses, 32 nurse managers, 9 unit managers, 30 nurse educators, and 41 nursing faculty. The participants were all members of the SPN. Sixty nurses worked in freestanding pediatric hospitals, 61 worked in the pediatric unit of a large general hospital/medical center, 13 worked in pediatric ambulatory care clinic settings, and 45 worked in schools of nursing. The level of education of the participants included diploma nurses (9), associate degree (16), baccalaureate (60), masters in nursing (71), doctor in nursing practice (3), and doctor of philosophy (PhD; 16). Years of experience as a pediatric nurse for the survey participants averaged 20.5 years (range = 2 44). Results Perceptions of Clinical Preparation Participants were first asked how prepared they personally felt when they were first hired. Most (59.5%) stated they felt they were adequately prepared, and an additional 13% felt they required minimal orientation. Participants were then asked to assess how prepared they felt the newly graduated nurses were who were hired to work on their unit. Specific to the perceived preparedness of newly graduate baccalaureate nurses who work with them, 36% (n = 50) of respondents reported that they found the baccalaureate nurses weakly prepared, 60% (n = 83) reported that the baccalaureate nurses were adequately prepared, and 4% (n = 5) reported that they required minimal orientation. When asked the same question specific to the newly graduated associate degree nurses, 47% (n = 60) reported that the associate degree nurses are weakly prepared, 50% (n = 65) reported that the associate degree nurses were adequately prepared, and 3% (n = 4) reported that they required minimal orientation. SPN member respondents were asked in an open-ended question to describe any changes they had observed in the pediatric patient population over the past 5 years in their setting. More than half of the respondents (n = 107) completed this item. These comments were analyzed using content analysis with the following themes identified. The overwhelming majority indicated that there was an increase in patient acuity. In addition to the higher acuity levels, patients in pediatric hospitals have higher technology needs. It was felt that students during their clinical rotation lack the critical thinking and clinical skills to meet the rapid changes of this patient population. An increase in chronic illness and higher numbers of children with obesity and diabetes were also noted. Some particularly interesting responses focused on family and psychosocial changes. Families need more help and have complex needs, educational needs, financial challenges including poverty and lack of insurance. The nurses reported that they felt challenged to work with or find time to work with families from admission to discharge. They also reported that they as nurses lacked the formal preparation to deal with these psychosocial issues. The reported shorter length of stay coupled with lower census due to more outpatient-based care and the higher acuity of the inpatient population translated into decreased opportunities for student nurses to learn. When asked if newly graduated nurses should be better prepared academically prior to hire into pediatric positions, 58% (n = 80) of respondents reported that yes they need more preparation. When specifically queried if newly graduate nurses need to be better prepared clinically for pediatric positions, 89% (n = 124) reported that yes they need more preparation. Nursing Educators Perception of Academic Preparation Nursing educators represented institutions offering a wide variety of types of nursing programs ranging from licensed practical nurse bachelor of science in nursing (BSN) 4% (n = 9), RN-BSN 23% (n = 47), BSN 26% (n = 53), master of science in nursing 24% (n = 49), doctor of nursing practice 10% (n = 20), to PhD 12% (n = 24). Nurse educators were also queried on specifics related to pediatric course theory and clinical in their nursing programs curriculum. Fifteen percent (n = 12) reported that their program offered only a pediatric theory course, whereas most, 52% (n = 43), reported having a freestanding combined

SPN News pediatric didactic/theory and clinical course. Six percent (n = 5) reported having a combined maternity and pediatric theory course, 20% (n = 16) reported having a combined maternity and pediatric course with theory and clinical, and 7% (n = 5) reported clinical and didactic integrated in a medical surgical course. The median number of theory clock hours for pediatric nursing content in specific programs' curriculum was 41 (ranging from 0 to 120). Several programs reported that this was difficult to quantify because the pediatric content is integrated throughout their program. The survey also asked about the amount of time devoted to pediatric clinical and what specific pediatric clinical sites were used in the undergraduate program. General pediatric unit was reported as the site that was used the most (51%, n = 74), followed by pediatric ambulatory clinics (26%, n = 34) and other sites 23% (n = 34). The reported median clock hours for clinical was 56 (range = none to 136). The nurse educator participants also were surveyed if they use simulation as part of clinical instruction. Most (62%, n = 48) reported that their academic programs used simulation as part of their pediatric nursing education. The amount of time simulation was used ranged from 2 to 55 hours, with median of 8 hours and mean of 9 hours. Reported simulation experiences ranged from use of trainex, case studies, skill demonstration such as medication administration, orientation to well baby care, physical assessment, and acute situation management (e.g., mock codes, respiratory distress). Use of human patient simulators was specifically indicated in more than half of these simulations. Discussion Although generalizations for the findings of this survey are limited due to the sample size and survey design, it is clear that most nurse managers, nurse educators, and staff nurses find the newly graduated nurse to lack preparation for practice in the pediatric setting. The nurses reported that newly graduate nurses must be prepared better for clinical experience. The question Is there a disconnect between what pediatric nurse educators teach or how they teach and the student outcomes? might be raised. Recommendations will be shared specific to nursing education, the clinical agencies, and the efforts of the SPN. However, the emerged themes specific to changes in the pediatric population over the past 5 years included higher acuity, chronic illnesses, technology needs, psychosocial needs of family, lack of clinical reasoning, opportunities not available to develop the needed skills, knowledge and clinical reasoning, and discrepancy between level of preparation and orientation needs as perceived by current nurses. The themes specific to health-related illness in the pediatric population and nursing student preparedness push faculty to consider the optimal teaching and learning resources to guide nursing students to practice nursing skills in a nonthreatening environment. The use of pediatric simulation with complex case studies can greatly benefit in fostering the critical thinking or clinical reasoning of students in a safe practice environment. Pediatric nursing content must remain part of a nursing program's curriculum to promote child and family healthy lifestyle and health promotion nursing students must be instructed with while in nursing school. Recommendation for Clinical Educators 601 Nursing education implications encompass curricular, content, and teaching strategy issues. As noted in the survey, there are several different curricular patterns or approaches to teaching pediatric nursing. These ranged from the freestanding course with lecture and clinical, a combined course with maternal health, to being a curriculum strand in an integrated curriculum. Research is needed to determine if any of these approaches are superior. However, for now, most programs can require a careful program assessment using a curriculum crosswalk to ensure that standards and essential knowledge and skills are provided. Course content, which must be clearly incorporated, includes nursing management of infants, children, and adolescents with high acuity and complex chronic health problems. Skills should include aspects of new technology. Another content area identified was the knowledge and skills to deal with the psychosocial needs of families. Although this aspect of family nursing could be addressed in the individual pediatric course, much of this content could be taught in a freestanding course on family nursing, since many of the skills, concepts, and constructs are common across the life span. One essential outcome or attribute that the newly graduated nurse could improve on as voiced by the pediatric managers and staff nurses is clinical reasoning (critical thinking). Many strategies are used in both didactic and clinical teaching situations to address this. From a curricular perspective, this is not just the responsibility of the pediatric nursing didactic and clinical classes alone. Clinical reasoning is a key curricular thread that must be developed across an entire program. So then the question comes to how to best teach pediatric nursing. Again, a lack of evidence base for many of the educational strategies confounds this issue. One part of the problem is that instructors often want to teach the way they were taught. Considering that the average age of nursing faculty is 55 years (www.aacn.nche.edu/ids) and assuming that they complete their basic nursing education more than 20 years ago, faculty might need to rethink how and what they teach. The days of the traditional pediatric clinical taking place on a general pediatric unit are gone. This is evidenced in the survey by the reported higher acuity of patients even on the general pediatric unit. The AACN Baccalaureate Essentials Toolkit recommends that across the nursing program, as students become

602 SPN News more experienced, increasingly complex clinical learning opportunities should be selected to develop the competence necessary for entry-level nurses (AACN, 2009). This competence is expected to be across the life span. However, the challenge pediatric nursing faculty face when dealing with program-wide curriculum issues is that our specialty/ content area is a minority. Most new graduates of nursing programs will not be employed in pediatric settings. How can academic programs, whose charge is to graduate a generalist nurse, produce individual nurses able to function in a specialty area such as pediatric hospitals? One traditional baccalaureate nursing program proposed addressing this issue in this way. All students in the nursing program will complete at the end of the sophomore level a freestanding 7-week course consisting of didactic (on campus class) and clinical. Clinical will include use of simulation and experience in a pediatric hospital. Select students have the opportunity to have their clinical experience in the seniorlevel, high acuity class in the pediatric hospital. In addition, select students can complete the 200-hour capstone practicum in a pediatric setting. This select group of students who have had extensive pediatric clinical experience during their academic program when hired should come well prepared and require minimal orientation, especially if the practicum was in the agency where they were hired. Simulation is one common strategy to better prepare students for the level of acuity of the pediatric acute care setting and used by most nurse educator respondents. The pediatric human patient simulator is an excellent tool to enhance student's clinical reasoning skills and ability to provide safe and accurate care to their patients independently (Benner, Sutphen, Leonard, & Day, 2009). In an acute care pediatric setting, students are limited in the skills that they are able to provide and typically provide care with the nurse, resulting in students not providing independent care to their patients. Since independent care is typically not possible in the pediatric hospital setting, the human patient simulator is a tool that can be used to allow for students to provide independent care and facilitate the student's clinical reasoning skills. In addition to the benefit of teaching nursing students to think critically with high-acuity patients in nonthreatening environments, students become more confident in their assessment and intervention skills (Jeffries & Rizzolo, 2006). Many nursing programs are using ambulatory clinics for pediatric clinical experiences. Those children who are seen in emergency departments also present with higher acuity of patients. Because of changes in health care delivery, many children with high acuity are cared for on an outpatient basis, and the very sick are admitted to hospitals. Clearly, nurses today need to be better prepared clinically to provide care to children who are very sick (Broussard et al., 2009; Lynch, 2007). Again, there continues to be a gap between theory and practice. This creates a dissonance between the knowledge that nursing students learn and the skills that they need to apply at the clinical setting (Burns & Poster, 2008). Recommendations for Clinical Agencies Pediatric nurse managers and nurse educators should revisit Benner's (1984) theory of skill when first hired. New-graduate nurses need to be parented when they are first hired. Nurse managers must also identify ways to help strengthen the skills of newly graduate nurses. Clinical immersion courses or practicum are recognized in education to enhance transition from student to professional nurse. Much of the successes of these programs rely on the support from the clinical agencies. Supports and rewards should be inherent in the pediatric agencies for nurses willing to precept students for their immersion or practicum there. Transition to practice programs have also been developed by pediatric agencies. Effective academic and practice partnerships ideally extend beyond graduation to the creation of supportive transition programs that specifically address the unique needs of the newly graduated nurse. Transition programs provide cost savings and positive long-term financial outcomes in terms of employee satisfaction, effectiveness, and reduced turnover. Residency programs in academic health centers can enhance job satisfaction and autonomy, increase critical reasoning skills, provide support to the graduate, and reduce turnover (Pine & Tart, 2007). Quality programs demonstrate ongoing efforts to forge and improve partnerships with practice settings to insure the effective integration of program graduates into the complex world of practice. Postgraduation residencies are one way to prepare the newly graduate. Recommendations for the SPN It has been more than 20 years since a core curriculum specific to pediatric nursing was proposed. In light of the updated baccalaureate essentials and Scope and Standards for Pediatric Nursing (2008), the Society should charge a select group of nurse educators and nurses active in pediatric practice to revisit, review, and revise as indicated the core curriculum. The SPN should convene groups to revisit the 1999 Core Curriculum with the goal of updating and revising them. In contrast to genomics and gerontological nursing, there are no specific resources cited specific to pediatric nursing education in the AACN Baccalaureate Essential Toolkit. After the core curriculum revision is completed, a comparable resource for pediatric nursing should be developed. The SPN should then advocate that the updated core curriculum with pediatric nursing toolkit be adopted as an addition to the current AACN toolkit. Conclusion A discrepancy exists between the level of preparation of newly graduate nurses for employment in pediatric acute

SPN News care settings and the orientation needs as perceived by the nurses currently working in those settings. Collaboration between pediatric health care settings and academic institutions should focus on addressing this to best meet the health care needs of children. Consistent with the call for radical transformation (Benner et al., 2009), the SPN can take the lead in coordinating this collaborative effort. References America Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. American Association of Colleges of Nursing. America Association of Colleges of Nursing. (2009). The essential of baccalaureate education for professional nursing practice: Faculty toolkit. American Association of Colleges of Nursing. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley. 603 Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating nurses: A call for radical transformation. Hobeken, New Jersey: Jossey-Bass. Broome, M. E., & Rollins, J. A. (1999). Core curriculum for the nursing care of children and their families. Pitman, New Jersey: Janetti. Broussard, L., Myers, R., & Lemoine, J. (2009). Preparing pediatric nurses: The role of simulation-based learning. Issues in Comprehensive Pediatric Nursing, 32, 4 15. Burns, P., & Poster, E. C. (2008). Competency development in new registered nurse graduates: Closing the gap between education and practice. The Journal of Continuing Education in Nursing, 39, 67 73. Jeffries, P. R., & Rizzolo, M. A. (2006). Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method model. National League for Nursing. Retrieved from the NLN web site http:// www.nln.org/research/laerdalreport.pdf. Lynch, M. E. (Ed.). (2007). Society of Pediatric Nurses Education Committee: Policy statement Child health content must remain in the undergraduate curriculum. Journal of Pediatric Nursing, 22, 87 89. Pine, R., & Tart, K. (2007). Return on investment: Benefits and challenges of a baccalaureate nurse residency program. Nursing Economics, 25, 13 39.