MEDICAL CARE
A short-term intensive training program for pediatric nurse practitioners A pediatric nurse practitioner course has been described in which 30 nurse trainees spent six weeks in an intensive training program followed by six months of preceptorship with a pediatrician in their own agency. This short but intensive program had the advantages o f permitting the PNP student to retain her health care agency position during the intensive part o f the program and o f assuring her a position as a PNP once the course was completed. Evaluation o f the students by written and practical examinations indicated that they had made significant gains in their knowledge and understanding of pediatrics and in their ability to evaluate and refer patients and to provide well-child care and maternal counseling.
Margaret H. Davidson, M.D., Catherine E. Burns, R.N., B.S., Joseph W. St. Geme, Jr., M.D., Sheila G. Cadman, R.N., M.A., Charlotte G. Neumann, M.D., M.P.H., Bonnie Bullough, R.N., Ph.D, and P a m e l a H e l l i n g s , R.N., M . N . , T o r r a n c e , Calif.
SINCE FIRST INTRODUCED by Silver and associates 1 and others 2, ~ the pediatric nurse practitioner has become an important member of the pediatric health care team. The problem is now one of how to prepare nurses adequately for this new role in a way that will correspond to the needs of the community. In, the Los Angeles area representatives of several pediatric health care agencies formed an Advisory Committee which developed a training program to prepare PNPs to work in association with pediatricians in a variety of settings. The agencies which collaborated in this effort to design a mutually satisfactory PNP program included two departments of pediatrics, the School of Nursing and the Extension of a major university, The Bureau of Maternal and Child Health of the County Health Department of a large, predominantly urban From the Division of Nursing, Continuing Education in Health Sciences, UCLA Extension," Department o f Pediatrics, Harbor General Hospital, UCLA School of Medicine; Department of Pediatrics, Center for the Health Sciences, UCL,4 School o f Medicine," and UCLA School o f Nursing. Supported by a grant from the California Regional Medical Programs, Area IV.
county and The Bureau of Maternal and Child Health of the State Health Department, pediatric outpatient departments of seven hospitals, a prepaid medical group, and the local pediatric society. The expressed need to keep the time the nurse-trainee would spend away from her agency at a minimum had to be balanced against the time required for adequate coverage of the essential aspects of Abbreviations used PNP: pediatric nurse practitioner DDST: Denver developmental screening test pediatric knowledge. Agency involvement was agreed upon as a means of extending the training period and of ensuring employment as a PNP for the trainee. Earlier programs conducted by St. Geme and associates? Weiss 5, and a pilot course conducted by the Advisory Committee 6 served as prototypes for the program. The final plan included a six-week intensive didactic program with a full-time faculty consisting of a PNP and a pediatrician, followed by a six-month preceptorship in the nurse's own agency. This program permitted the trainee to retain her health care agency position and assured her of a position as a PNP once the course was completed. The Journal of PEDIATRICS Vol. 87, No. 2, p. 315-320
315
3 16
Davidson et aL
The Journal of Pediatrics August 1975
Table I. Background of PNP students Variable
No. of students
Age 21 - 30 yr 15 31 - 40 yr 10 41 - 50 yr 5 (Av 32.8, Range 24 - 48 yr) Education Diploma (RN) 6 Bachelor's degree (RN + BS) 19 Master's degree 5 Experience in pediatrics Less than 2 yr 5 2- 7yr 16 7.5 - 15 yr 9 (Av 5.2, Range 0 - 15 yr) Agency of employment County of Los Angeles Department of Health Services Child Health Conference 11 Child and Youth Clinic 2 County Health Department other than 4 Los Angeles Hospital outpatient department 6 Head Start program 3 School health program 1 Private pediatrician 3
The following goals were established for the graduates of the PNP program: (1) to be able to collect subjective and objective data including history, physical examination, neurologic examination, measurement of growth and development, Denver developmental screening test 7- 8 Denver articulation screening exam, ~ vision and hearing testing, and the use of routine laboratory studies; (2) to be able to detect and assess health problems, including those relating to performance in school; (3) to be able to carry out health care plans including immunizations, maternal counseling, and the symptomatic management of minor and uncomplicated dermatologic, upper respiratory, and gastrointestinal problems; and (4) to be aware of the indications for referral of the patient to the physician. It was projected that the PNP graduate should be able to function equally well in "well-baby" clinics, newborn nurseries, triage clinics in ambulatory care units, private and prepaid pediatric offices, Head Start programs, and school health programs. In addition, nurses with this background should be able, with additional in-service training, to become PNP specialists in cardiology, orthopaedics, or allergy. STUDENTS The 30 nurses who took the course were divided into five groups of six each to provide for close faculty
supervision, easier incorporation of students into ongoing clinics, and more effective bedside teaching. Students were selected on the basis of nursing education, work experience in pediatrics, degree of independence achieved, and agency need. Applicants were required to have arranged for an adequate preceptorship in an agency which would employ the trainee as a PNP upon completion of the course. They also had to be free of other work or course responsibilities during the six-week program. Students were selected from varied locations and agencies in Central and Southern California. The background of the students is presented in Table I. CURRICULUM The six-week program was taught by a pediatric nurse practitioner (C. B.), a pediatrician (M. D.), co-authors (J. S., C. N., and B. B.), and invited specialists. One-third of the academic curriculum (about 64 hours) was devoted to lectures that covered pertinent aspects of physical diagnosis, diseases in children, growth and development, health supervision, and the PNP role including its legal status. Lectures on diseases focused upon clinical and physical diagnosis and the indications for referral of the patients to the physician rather than upon treatment and diagnostic studies. The pharmacology of antibiotics and other prescription medications was not discussed nor were the students taught to do or interpret lumbar punctures, electrocardiograms, etc. since these would be handled by the physician member of the team. Symptomatic treatment of uncomplicated upper respiratory infections, diarrhea and vomiting, diaper rash, feeding, and behavior problems was discussed. Discussion of chronic diseases was omitted except for a few conditions such as asthma and diabetes in which the PNP might play an important role in patient care. Fig. 1 summarizes the distribution of time during the six-week academic program. One-third of the six weeks was devoted to pediatric clinics; one-half of this time (27-32 hours) was spent in "well-baby" clinics. In these clinics the students had an opportunity to practice their newly acquired skills in a closely supervised setting. The students also provided maternal counseling and formulated a plan for further care of the patient. Specialty clinics were selected for a high frequency of abnormal findings; areas of 'physical diagnosis which were difficult for a majority of the students, specifically cardiology and neurology; and areas in which problems are most often seen in well-child care, namely, dermatology, orthopaedics, and allergy. Each student spent four half days in an ambulatory pediatric setting examining acutely ill children. Examination of inpatients helped the students to
Volume 87 Number 2
Intensive training for PNPs
become familiar with a wide range of abnormal physical findings. Weekly teaching rounds enabled students to present cases and discuss them from the standpoint of the PNP role in detection, referral, and care. A neonatal unit and orthopaedic ward provided additional inpatient experience. The students were given a quiz each Friday on the lecture material of the week. The quizzes served to indicate areas of instruction which were incompletely comprehended by the group as a whole, to detect students who were having problems with the course material, and to re-emphasize important points made during the preceding week. During the preceptorship, students were required to spend 100% of their time in pediatrics. Half of this time was to be devoted to PNP clinics in which the trainee saw her own patients under the guidance of a pediatrician in her own agency. The closeness with which the preceptor worked with the trainee varied from a constant one-to-one association to a general supervisory role with some of the instruction shared by other physicians in the agency. Students were expected to increase their patient load from two or three to approximately ten patients per half-day clinic session over the six-month period. The PNP instructor visited the students during their preceptorship to observe them work and to help to correct or avoid problems. Once a month the students met with the PNP instructor for seminars in which they reported their progress, discussed problems, and attended a lecture on an area of special interest. STUDENT
EVALUATION
The evaluation of student performance during the course of the training program included three written and two p~ractical examinations. The comprehensive written examinations were given at the beginning o f the course (pretest), after the six-week academic program (six-week test), a n d after the six months of preceptorship (7 89 test). The pretest was extensively revised after the first 12 students had taken it, to include 96 questions from the six-week test and 43 questions which were repeated on both subsequent tests (161 questions; 508 points). The comprehensive examination given at six weeks covered the subject material of the academic program and was regarded as the principal measure of academic achievement. This test was also given to 14 UCLA junior medical students at the end of their pediatric clerkship (143 questions; 571 points). The 789 month final examination contained many questions from the pretest and the six-week test plus additional questions testing clinical judgment (136 questions; 527 points). The PNP students took the written examination in pediatrics
~
3 17
3 5 . 3 %"
Fig. 1. Distribution (%) of the students' time which was devoted to lectures, clinics, inpatient examination, tests, films, and tapes during the six weeks of intensive training. given to UCLA medical students at the conclusion of their sophomore course in physical diagnosis; 17 students were also given the examination designed for the Yale PNP course. A practical examination was given at the conclusion of 9the academic program and after the preceptorship. Without benefit of notes, the students were expected to take a history from a mother and perform a physical examination and DDST on her baby. In the six-week evaluation the examiner checked each step of the student's performance on a prepared list and gave her a letter grade based chiefly upon thoroughness. The examiners, many of whom had been involved in the practical examination of medical students, pediatric house officers, and, in two instances, Pediatric Board examinations, did not include the physician or the PNP instructor. After the preceptorship, this evaluation was repeated and the examiner also rated the PNP by the more qualitative "Criteria for Evaluating Performance on Physical Examination .... developed at the University of Colorado, which requires an assessment of interviewing and counseling skills, organization, and clinical judgment. In this instance the examiners included the instructors. Evaluation of the course and faculty by the students was helpful in curricular revision throughout the year. During the preceptorship, the nurses were asked to record the following: the number of patients seen and their presenting complaints; opportunities for continuing education including lectures, conferences, and reading material; preceptor contact; and any problems which they encountered. These data were reviewed by the PNP instructor and used to correct any problems or deficiendes. At the end of the preceptorship the students were
3 18
Davidsonet al.
The Journal of Pediatrics August 1975
Table If. Comparison of PNP program students and UCLA medical students
I No. of students [ Av grade PNP six-week final examination PNP students Junior medical students Sophomore medical student examination in pediatrics PNP students Sophomore medical students
30 14
82.6% 78.0%
30 137
68.1% 70.0%
asked to evaluate the seminars, the quality of the preceptorship, and the supervision by the PNP instructor. The physician-preceptor in the nurse's agency was asked to evaluate the PNP trainee at three and at six months regarding history and physical examination techniques, chart recording, knowledge of pediatrics, teaching skills, counseling skills, performance of procedures, organization, role acceptance, and leadership. RESULTS
OF STUDENT
EVALUATION
The performance of the students on the major examinations was used to evaluate both the students and the course. The average grades, 61.0% on the pretest, 82.6% at six weeks, and 83.2% at seven and one-half months, indicate improved performance at the end of the six-week intensive program with essentially no change after the preceptorship. Individual grades on the six-week examination were not significantly related to student age, educational background, years of experience in pediatrics, health care agency, or a variety of other factors which could conceivably have been useful in the selection o f students. This is not surprising since all but six students had grades ranging from 80-89%. There was also no correlation between pretest grades and six-week examination grades, eliminating the pretest as an effective admission test. This is in agreement with earlier experiences with PNP training. 6 For a more objective comparison, the last three groups of students were given examinations which included 43 identical questions. The difference in paired values between the pretest grades (av 46.9%) and the six-week test grades (av 83.0%) on these questions was highly significant (p < < 0.001, Students "t" test for paired values). In the largely clinical preceptorship, there was relatively little overall improvement in written test performance (av 86.8%) (p > 0.05). Division by subject content of the 96 questions which were the Same on the pretest and the six-week test indicated that the students showed the greatest improvement on the questions pertaining to physical diagnosis and signs and symptoms.
The average grade on 44 questions intended to test clinical judgment on the seven and one-half-month test was 82.O%. PNP test performance is compared with that of junior and sophomore medical students in Table II. The test scores of the two groups are comparable, suggesting a degree of correlation of subject matter between the two training programs. The scores of 17 students who took the examination of the Yale PNP program compared favorably with those of other PNPs who had taken this test. Students performed well on the six-week practical examination; 21 students received "A's." By the end of the six months of preceptorship, many students were performing in a highly efficient and well-organized manner. Most students were rated as "satisfactory" to "superior" on the items on the Denver "Criteria for Evaluating Performance on Physical Examination." Clinical acumen and clinical judgment were generally found to be appropriate to the situations presented by the practical examination. Students were found to be skilled and informed in maternal counseling regarding common well-child problems. Preceptor evaluation of the students corresponded closely to that by the instructors. However, preceptors observed an increase in knowledge of pediatrics during the six months. Since this is not borne out by test results, it may reflect an increase in communication between the trainee and the preceptor over the six-month period. Two students were required to extend their preceptorships: one because of ill health and another because of the temporary lack of an adequate preceptor. One student was not graduated because of overall performance significantly below that of the other students and below the standards set for the course. To date the graduates of the program have continued to work as PNPs. DISCUSSION Experiences with the first 30 students support the practicability of a course consisting of a six-week intensive program followed by six months of preceptorship in the nurse's own agency. Although the intensive part of the program was relatively short compared with earlier programs, the number of hours of lecture per week was greater.~. 11 The gains which the students made on comprehensive written examinations and their satisfactory performance on practical examinations, as judged by numerous observers, support the feasibility of this type of program and indicate that it is possible, in a relatively short period of time, to teach and to learn a large body of basic pediatric knowledge fundamental to pediatric physical diagnosis and informed patient evaluation, screening, and counseling.
Volume 87 Number 2
Several factors contributed to the success of the program: Well-qualified students, as indicated by their training and experience and by their pretest performance in areas relating to nursing, were ready to progress to the new material presented. Previous experience in interviewing and counseling, which almost all students had, facilitated with particular aspect of their training. The ability of students and instructors to devote all of their attention to the course during the six-week period was essential. Consideration of the specific needs of the PNP was vital to the best utilization of time. Emphasis was placed upon early signs and symptoms of diseases and indications for referral, rather than upon tests and therapeutic regimens which the physician member of the team would be better qualified to perform. Lastly, the extensive use of quizzes and examinations helped to re-emphasize and teach a large body of facts within a short period of time. Students were noted to perform better on the sixweek test on subjects which had been covered in quizzes. The pretest also appeared to help students to focus upon certain areas. The seven and one-half-month test showed that learning of didactic material did not continue at the same pace after the six-week program. In fact, during largely clinical preceptorships in which the students became noticeably more proficient in physical examination and counseling skills, some appeared to have forgotten some of the didactic material while others continued to learn, but at a slower rate. Other programs have evaluated the acceptance of nurse practitioners and have found that patients respond favorably to care by a PNP. 4, 12-, We made no surveys of patient response but found in general that our students were accepted even early in their training. They were introduced as "registered nurses" who were taking additional training so that they could provide child health care in association with pediatricians. The parents responded in a manner which suggested confidence in the ability of a "registered nurse" to give health care. Many of the parents seemed to appreciate the extra attention their problems received from the PNP, including the DDST. As with the pilot program, ~ overconfidence was not a major problem with our students. Conversely, most of them did not have problems adjusting to their new role. 15 This has been attributed partly to the presence of role models, which included the PNP instructor and other PNPs working in some of the agencies in which the PNPs received their training. The increased job satisfaction ~ and the improved utilization of the nurses' training, skills, and time/, ,7, ,8 which have been described by others, appeared to apply to our students as well. A quotation from Silver and
Intensive training for PNPs
3 19
associates 19 summarizes most succinctly the effect of the PNP concept on child health care: "The program has resulted in a realignment of functions performed by physicians and nurses so that each of them can assume responsibility for those aspects of the patient's needs that they can perform most effectively." ADDENDUM Forty-six additional students have taken the course with results similar to those presented here.
REFERENCES
1. SilverHK, Ford LC, and Stearly SG: A program to increase health care for children: The pediatric nurse practitioner program, Pediatrics 39:756, 1967. 2. Andrews P, Yankauer A, and Connelly JP: Changing the patterns of ambulatory pediatric caretaking: An actionoriented training program for nurses, Am J Public Health 60:870, 1970. 3. Connelly JP, and Yankauer A: Allied health personnel in child health care, Pediatr Clin North Am 16:921, 1969~ 4. St. Geme JW Jr, Turner AB, Peirson GS, and Gabel MD: A curricular experiment with the nurse pediatrist, Am J Dis Child 122:!95, 1971. 5. WeissRC: The nursing child health conference: A physician's viewpoint, presented at the Conference for Nurses in Child Health: co-sponsored by American Academy of Pediatrics and California Nurses' Association, San Francisco, 1967. 6. Bullough B, St. Geme JW Jr, and Neumann CG: Pediatric nurse practitioners-issues in training, Health Serv Rep 88:767-1973. 7. Frankenburg WK, and Dodds JB: The Denver Developmental Screening Test, J PEDIATR7!:181, 1967. 8. Frankenburg WK, Goldstein AD, and Camp BS: The revised Denver Developmental Screening Test: Its accuracy as a screening instrument, J P~DIATR79:988, 1971. 9. Drumright AF: The Denver Articulation Screening Exam. University of Colorado Medical Center, Lit 16, 17, and 18, 10/71. 10. Dungy CI: Quantitative evaluation of health professional students' performance on physical examinations, Clin Res 21:299, 1973. 11. A joint statement of the American Nurses' Association, Division on Maternal and Child Health Nursing Practice, and the American Academy of Pediatrics: Guidelines on short-term continuing education programs for pediatric nurse associates, Pediatrics 47:1075, 1971. 12. Day LR, Egli R, and Silver HK: Acceptance of pediatric nmse practitioners: Parents' opinion of combined care by a pediatrician and a pediatric nurse practitioner in private practice, Am J Dis Child 119:204, 1970. 13. Chappell JA, and Drogos PA: Evaluation of infant health care by a nurse practitioner, Pediatrics 49:871, 1972. 14. SpitzerWO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, Hackett BC, and Olynech A: The Burlington randomized trial of the nurse practitioner, N Engl J Med 290:251, 1974. 15. SilverHK, and Hecker JA: The pediatric nurse practitioner
320
Davidson et al.
and the child health associate: New types of health professionals, J Med Educ 45:171, 1970. 16. ~ullough B: Is the nurse practitioner rote a source of ~ncreased work satisfaction? Nurs Res 23:14, 1974. 17. SilverHK, and Duncan B: Time-m0tion study of pediatric nurse practitioners: Comparison with ',regular" office nurses and pediatricians, J PEDIATR79:331, 1971. 18. Heagarty MD, Boehringer JR, Lavigne PA, Brooks EG, and
The Journal of Pediatrics August 1975
Evans ME" An evaluation of the activities of nurses and pediatricians in a university outpatient department, J PED~ATR83:875, 1973. 19, Silver HK, Ford LC, and Day LR: The pediatric nurse practitioner program. Expanding the role of the nurse to provide increased health care for childreia, JAMA 204:298, 1968.
A short-term intensive training program for pediatric nurse practitioners A pediatric nurse practitioner course has been described in which 30 nurse trainees spent six weeks in an intensive training program followed by six months of preceptorship with a pediatrician in their own agency. This short but intensive program had the advantages o f permitting the PNP student to retain her health care agency position during the intensive part o f the program and o f assuring her a position as a PNP once the course was completed. Evaluation o f the students by written and practical examinations indicated that they had made significant gains in their knowledge and understanding of pediatrics and in their ability to evaluate and refer patients and to provide well-child care and maternal counseling.
Margaret H. Davidson, M.D., Catherine E. Burns, R.N., B.S., Joseph W. St. Geme, Jr., M.D., Sheila G. Cadman, R.N., M.A., Charlotte G. Neumann, M.D., M.P.H., Bonnie Bullough, R.N., Ph.D, and P a m e l a H e l l i n g s , R.N., M . N . , T o r r a n c e , Calif.
SINCE FIRST INTRODUCED by Silver and associates 1 and others 2, ~ the pediatric nurse practitioner has become an important member of the pediatric health care team. The problem is now one of how to prepare nurses adequately for this new role in a way that will correspond to the needs of the community. In, the Los Angeles area representatives of several pediatric health care agencies formed an Advisory Committee which developed a training program to prepare PNPs to work in association with pediatricians in a variety of settings. The agencies which collaborated in this effort to design a mutually satisfactory PNP program included two departments of pediatrics, the School of Nursing and the Extension of a major university, The Bureau of Maternal and Child Health of the County Health Department of a large, predominantly urban From the Division of Nursing, Continuing Education in Health Sciences, UCLA Extension," Department o f Pediatrics, Harbor General Hospital, UCLA School of Medicine; Department of Pediatrics, Center for the Health Sciences, UCL,4 School o f Medicine," and UCLA School o f Nursing. Supported by a grant from the California Regional Medical Programs, Area IV.
county and The Bureau of Maternal and Child Health of the State Health Department, pediatric outpatient departments of seven hospitals, a prepaid medical group, and the local pediatric society. The expressed need to keep the time the nurse-trainee would spend away from her agency at a minimum had to be balanced against the time required for adequate coverage of the essential aspects of Abbreviations used PNP: pediatric nurse practitioner DDST: Denver developmental screening test pediatric knowledge. Agency involvement was agreed upon as a means of extending the training period and of ensuring employment as a PNP for the trainee. Earlier programs conducted by St. Geme and associates? Weiss 5, and a pilot course conducted by the Advisory Committee 6 served as prototypes for the program. The final plan included a six-week intensive didactic program with a full-time faculty consisting of a PNP and a pediatrician, followed by a six-month preceptorship in the nurse's own agency. This program permitted the trainee to retain her health care agency position and assured her of a position as a PNP once the course was completed. The Journal of PEDIATRICS Vol. 87, No. 2, p. 315-320
315
3 16
Davidson et aL
The Journal of Pediatrics August 1975
Table I. Background of PNP students Variable
No. of students
Age 21 - 30 yr 15 31 - 40 yr 10 41 - 50 yr 5 (Av 32.8, Range 24 - 48 yr) Education Diploma (RN) 6 Bachelor's degree (RN + BS) 19 Master's degree 5 Experience in pediatrics Less than 2 yr 5 2- 7yr 16 7.5 - 15 yr 9 (Av 5.2, Range 0 - 15 yr) Agency of employment County of Los Angeles Department of Health Services Child Health Conference 11 Child and Youth Clinic 2 County Health Department other than 4 Los Angeles Hospital outpatient department 6 Head Start program 3 School health program 1 Private pediatrician 3
The following goals were established for the graduates of the PNP program: (1) to be able to collect subjective and objective data including history, physical examination, neurologic examination, measurement of growth and development, Denver developmental screening test 7- 8 Denver articulation screening exam, ~ vision and hearing testing, and the use of routine laboratory studies; (2) to be able to detect and assess health problems, including those relating to performance in school; (3) to be able to carry out health care plans including immunizations, maternal counseling, and the symptomatic management of minor and uncomplicated dermatologic, upper respiratory, and gastrointestinal problems; and (4) to be aware of the indications for referral of the patient to the physician. It was projected that the PNP graduate should be able to function equally well in "well-baby" clinics, newborn nurseries, triage clinics in ambulatory care units, private and prepaid pediatric offices, Head Start programs, and school health programs. In addition, nurses with this background should be able, with additional in-service training, to become PNP specialists in cardiology, orthopaedics, or allergy. STUDENTS The 30 nurses who took the course were divided into five groups of six each to provide for close faculty
supervision, easier incorporation of students into ongoing clinics, and more effective bedside teaching. Students were selected on the basis of nursing education, work experience in pediatrics, degree of independence achieved, and agency need. Applicants were required to have arranged for an adequate preceptorship in an agency which would employ the trainee as a PNP upon completion of the course. They also had to be free of other work or course responsibilities during the six-week program. Students were selected from varied locations and agencies in Central and Southern California. The background of the students is presented in Table I. CURRICULUM The six-week program was taught by a pediatric nurse practitioner (C. B.), a pediatrician (M. D.), co-authors (J. S., C. N., and B. B.), and invited specialists. One-third of the academic curriculum (about 64 hours) was devoted to lectures that covered pertinent aspects of physical diagnosis, diseases in children, growth and development, health supervision, and the PNP role including its legal status. Lectures on diseases focused upon clinical and physical diagnosis and the indications for referral of the patients to the physician rather than upon treatment and diagnostic studies. The pharmacology of antibiotics and other prescription medications was not discussed nor were the students taught to do or interpret lumbar punctures, electrocardiograms, etc. since these would be handled by the physician member of the team. Symptomatic treatment of uncomplicated upper respiratory infections, diarrhea and vomiting, diaper rash, feeding, and behavior problems was discussed. Discussion of chronic diseases was omitted except for a few conditions such as asthma and diabetes in which the PNP might play an important role in patient care. Fig. 1 summarizes the distribution of time during the six-week academic program. One-third of the six weeks was devoted to pediatric clinics; one-half of this time (27-32 hours) was spent in "well-baby" clinics. In these clinics the students had an opportunity to practice their newly acquired skills in a closely supervised setting. The students also provided maternal counseling and formulated a plan for further care of the patient. Specialty clinics were selected for a high frequency of abnormal findings; areas of 'physical diagnosis which were difficult for a majority of the students, specifically cardiology and neurology; and areas in which problems are most often seen in well-child care, namely, dermatology, orthopaedics, and allergy. Each student spent four half days in an ambulatory pediatric setting examining acutely ill children. Examination of inpatients helped the students to
Volume 87 Number 2
Intensive training for PNPs
become familiar with a wide range of abnormal physical findings. Weekly teaching rounds enabled students to present cases and discuss them from the standpoint of the PNP role in detection, referral, and care. A neonatal unit and orthopaedic ward provided additional inpatient experience. The students were given a quiz each Friday on the lecture material of the week. The quizzes served to indicate areas of instruction which were incompletely comprehended by the group as a whole, to detect students who were having problems with the course material, and to re-emphasize important points made during the preceding week. During the preceptorship, students were required to spend 100% of their time in pediatrics. Half of this time was to be devoted to PNP clinics in which the trainee saw her own patients under the guidance of a pediatrician in her own agency. The closeness with which the preceptor worked with the trainee varied from a constant one-to-one association to a general supervisory role with some of the instruction shared by other physicians in the agency. Students were expected to increase their patient load from two or three to approximately ten patients per half-day clinic session over the six-month period. The PNP instructor visited the students during their preceptorship to observe them work and to help to correct or avoid problems. Once a month the students met with the PNP instructor for seminars in which they reported their progress, discussed problems, and attended a lecture on an area of special interest. STUDENT
EVALUATION
The evaluation of student performance during the course of the training program included three written and two p~ractical examinations. The comprehensive written examinations were given at the beginning o f the course (pretest), after the six-week academic program (six-week test), a n d after the six months of preceptorship (7 89 test). The pretest was extensively revised after the first 12 students had taken it, to include 96 questions from the six-week test and 43 questions which were repeated on both subsequent tests (161 questions; 508 points). The comprehensive examination given at six weeks covered the subject material of the academic program and was regarded as the principal measure of academic achievement. This test was also given to 14 UCLA junior medical students at the end of their pediatric clerkship (143 questions; 571 points). The 789 month final examination contained many questions from the pretest and the six-week test plus additional questions testing clinical judgment (136 questions; 527 points). The PNP students took the written examination in pediatrics
~
3 17
3 5 . 3 %"
Fig. 1. Distribution (%) of the students' time which was devoted to lectures, clinics, inpatient examination, tests, films, and tapes during the six weeks of intensive training. given to UCLA medical students at the conclusion of their sophomore course in physical diagnosis; 17 students were also given the examination designed for the Yale PNP course. A practical examination was given at the conclusion of 9the academic program and after the preceptorship. Without benefit of notes, the students were expected to take a history from a mother and perform a physical examination and DDST on her baby. In the six-week evaluation the examiner checked each step of the student's performance on a prepared list and gave her a letter grade based chiefly upon thoroughness. The examiners, many of whom had been involved in the practical examination of medical students, pediatric house officers, and, in two instances, Pediatric Board examinations, did not include the physician or the PNP instructor. After the preceptorship, this evaluation was repeated and the examiner also rated the PNP by the more qualitative "Criteria for Evaluating Performance on Physical Examination .... developed at the University of Colorado, which requires an assessment of interviewing and counseling skills, organization, and clinical judgment. In this instance the examiners included the instructors. Evaluation of the course and faculty by the students was helpful in curricular revision throughout the year. During the preceptorship, the nurses were asked to record the following: the number of patients seen and their presenting complaints; opportunities for continuing education including lectures, conferences, and reading material; preceptor contact; and any problems which they encountered. These data were reviewed by the PNP instructor and used to correct any problems or deficiendes. At the end of the preceptorship the students were
3 18
Davidsonet al.
The Journal of Pediatrics August 1975
Table If. Comparison of PNP program students and UCLA medical students
I No. of students [ Av grade PNP six-week final examination PNP students Junior medical students Sophomore medical student examination in pediatrics PNP students Sophomore medical students
30 14
82.6% 78.0%
30 137
68.1% 70.0%
asked to evaluate the seminars, the quality of the preceptorship, and the supervision by the PNP instructor. The physician-preceptor in the nurse's agency was asked to evaluate the PNP trainee at three and at six months regarding history and physical examination techniques, chart recording, knowledge of pediatrics, teaching skills, counseling skills, performance of procedures, organization, role acceptance, and leadership. RESULTS
OF STUDENT
EVALUATION
The performance of the students on the major examinations was used to evaluate both the students and the course. The average grades, 61.0% on the pretest, 82.6% at six weeks, and 83.2% at seven and one-half months, indicate improved performance at the end of the six-week intensive program with essentially no change after the preceptorship. Individual grades on the six-week examination were not significantly related to student age, educational background, years of experience in pediatrics, health care agency, or a variety of other factors which could conceivably have been useful in the selection o f students. This is not surprising since all but six students had grades ranging from 80-89%. There was also no correlation between pretest grades and six-week examination grades, eliminating the pretest as an effective admission test. This is in agreement with earlier experiences with PNP training. 6 For a more objective comparison, the last three groups of students were given examinations which included 43 identical questions. The difference in paired values between the pretest grades (av 46.9%) and the six-week test grades (av 83.0%) on these questions was highly significant (p < < 0.001, Students "t" test for paired values). In the largely clinical preceptorship, there was relatively little overall improvement in written test performance (av 86.8%) (p > 0.05). Division by subject content of the 96 questions which were the Same on the pretest and the six-week test indicated that the students showed the greatest improvement on the questions pertaining to physical diagnosis and signs and symptoms.
The average grade on 44 questions intended to test clinical judgment on the seven and one-half-month test was 82.O%. PNP test performance is compared with that of junior and sophomore medical students in Table II. The test scores of the two groups are comparable, suggesting a degree of correlation of subject matter between the two training programs. The scores of 17 students who took the examination of the Yale PNP program compared favorably with those of other PNPs who had taken this test. Students performed well on the six-week practical examination; 21 students received "A's." By the end of the six months of preceptorship, many students were performing in a highly efficient and well-organized manner. Most students were rated as "satisfactory" to "superior" on the items on the Denver "Criteria for Evaluating Performance on Physical Examination." Clinical acumen and clinical judgment were generally found to be appropriate to the situations presented by the practical examination. Students were found to be skilled and informed in maternal counseling regarding common well-child problems. Preceptor evaluation of the students corresponded closely to that by the instructors. However, preceptors observed an increase in knowledge of pediatrics during the six months. Since this is not borne out by test results, it may reflect an increase in communication between the trainee and the preceptor over the six-month period. Two students were required to extend their preceptorships: one because of ill health and another because of the temporary lack of an adequate preceptor. One student was not graduated because of overall performance significantly below that of the other students and below the standards set for the course. To date the graduates of the program have continued to work as PNPs. DISCUSSION Experiences with the first 30 students support the practicability of a course consisting of a six-week intensive program followed by six months of preceptorship in the nurse's own agency. Although the intensive part of the program was relatively short compared with earlier programs, the number of hours of lecture per week was greater.~. 11 The gains which the students made on comprehensive written examinations and their satisfactory performance on practical examinations, as judged by numerous observers, support the feasibility of this type of program and indicate that it is possible, in a relatively short period of time, to teach and to learn a large body of basic pediatric knowledge fundamental to pediatric physical diagnosis and informed patient evaluation, screening, and counseling.
Volume 87 Number 2
Several factors contributed to the success of the program: Well-qualified students, as indicated by their training and experience and by their pretest performance in areas relating to nursing, were ready to progress to the new material presented. Previous experience in interviewing and counseling, which almost all students had, facilitated with particular aspect of their training. The ability of students and instructors to devote all of their attention to the course during the six-week period was essential. Consideration of the specific needs of the PNP was vital to the best utilization of time. Emphasis was placed upon early signs and symptoms of diseases and indications for referral, rather than upon tests and therapeutic regimens which the physician member of the team would be better qualified to perform. Lastly, the extensive use of quizzes and examinations helped to re-emphasize and teach a large body of facts within a short period of time. Students were noted to perform better on the sixweek test on subjects which had been covered in quizzes. The pretest also appeared to help students to focus upon certain areas. The seven and one-half-month test showed that learning of didactic material did not continue at the same pace after the six-week program. In fact, during largely clinical preceptorships in which the students became noticeably more proficient in physical examination and counseling skills, some appeared to have forgotten some of the didactic material while others continued to learn, but at a slower rate. Other programs have evaluated the acceptance of nurse practitioners and have found that patients respond favorably to care by a PNP. 4, 12-, We made no surveys of patient response but found in general that our students were accepted even early in their training. They were introduced as "registered nurses" who were taking additional training so that they could provide child health care in association with pediatricians. The parents responded in a manner which suggested confidence in the ability of a "registered nurse" to give health care. Many of the parents seemed to appreciate the extra attention their problems received from the PNP, including the DDST. As with the pilot program, ~ overconfidence was not a major problem with our students. Conversely, most of them did not have problems adjusting to their new role. 15 This has been attributed partly to the presence of role models, which included the PNP instructor and other PNPs working in some of the agencies in which the PNPs received their training. The increased job satisfaction ~ and the improved utilization of the nurses' training, skills, and time/, ,7, ,8 which have been described by others, appeared to apply to our students as well. A quotation from Silver and
Intensive training for PNPs
3 19
associates 19 summarizes most succinctly the effect of the PNP concept on child health care: "The program has resulted in a realignment of functions performed by physicians and nurses so that each of them can assume responsibility for those aspects of the patient's needs that they can perform most effectively." ADDENDUM Forty-six additional students have taken the course with results similar to those presented here.
REFERENCES
1. SilverHK, Ford LC, and Stearly SG: A program to increase health care for children: The pediatric nurse practitioner program, Pediatrics 39:756, 1967. 2. Andrews P, Yankauer A, and Connelly JP: Changing the patterns of ambulatory pediatric caretaking: An actionoriented training program for nurses, Am J Public Health 60:870, 1970. 3. Connelly JP, and Yankauer A: Allied health personnel in child health care, Pediatr Clin North Am 16:921, 1969~ 4. St. Geme JW Jr, Turner AB, Peirson GS, and Gabel MD: A curricular experiment with the nurse pediatrist, Am J Dis Child 122:!95, 1971. 5. WeissRC: The nursing child health conference: A physician's viewpoint, presented at the Conference for Nurses in Child Health: co-sponsored by American Academy of Pediatrics and California Nurses' Association, San Francisco, 1967. 6. Bullough B, St. Geme JW Jr, and Neumann CG: Pediatric nurse practitioners-issues in training, Health Serv Rep 88:767-1973. 7. Frankenburg WK, and Dodds JB: The Denver Developmental Screening Test, J PEDIATR7!:181, 1967. 8. Frankenburg WK, Goldstein AD, and Camp BS: The revised Denver Developmental Screening Test: Its accuracy as a screening instrument, J P~DIATR79:988, 1971. 9. Drumright AF: The Denver Articulation Screening Exam. University of Colorado Medical Center, Lit 16, 17, and 18, 10/71. 10. Dungy CI: Quantitative evaluation of health professional students' performance on physical examinations, Clin Res 21:299, 1973. 11. A joint statement of the American Nurses' Association, Division on Maternal and Child Health Nursing Practice, and the American Academy of Pediatrics: Guidelines on short-term continuing education programs for pediatric nurse associates, Pediatrics 47:1075, 1971. 12. Day LR, Egli R, and Silver HK: Acceptance of pediatric nmse practitioners: Parents' opinion of combined care by a pediatrician and a pediatric nurse practitioner in private practice, Am J Dis Child 119:204, 1970. 13. Chappell JA, and Drogos PA: Evaluation of infant health care by a nurse practitioner, Pediatrics 49:871, 1972. 14. SpitzerWO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, Hackett BC, and Olynech A: The Burlington randomized trial of the nurse practitioner, N Engl J Med 290:251, 1974. 15. SilverHK, and Hecker JA: The pediatric nurse practitioner
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and the child health associate: New types of health professionals, J Med Educ 45:171, 1970. 16. ~ullough B: Is the nurse practitioner rote a source of ~ncreased work satisfaction? Nurs Res 23:14, 1974. 17. SilverHK, and Duncan B: Time-m0tion study of pediatric nurse practitioners: Comparison with ',regular" office nurses and pediatricians, J PEDIATR79:331, 1971. 18. Heagarty MD, Boehringer JR, Lavigne PA, Brooks EG, and
The Journal of Pediatrics August 1975
Evans ME" An evaluation of the activities of nurses and pediatricians in a university outpatient department, J PED~ATR83:875, 1973. 19, Silver HK, Ford LC, and Day LR: The pediatric nurse practitioner program. Expanding the role of the nurse to provide increased health care for childreia, JAMA 204:298, 1968.
