ORIGINAL
ARTICLE
New Challenges,New
Answers: Pediatric
Nurse Practitioners and
the Care of Adolescents
F
b
Peggy
MS,
Elizabeth
Nerdahl,
RN,
CPNP,
Saewyc,
nhtions&&ors
a~~~a~~w~~
July/August
1999
’
RN,
lCPNP,
Linda
H.
Bearinger,
PhD(c),
& Theora
self-perceived knowLed$&r
ski11
and krterest in training~for ~8 cornmon health concerns & ad&scm%
were arm!yzed wing l&i sqmref r
test, and Pearson’s correlation. Bar&
&s and attractions to working with
adolescents were alsa investigatid”
Rest&x The greatest deficits in selfperceived knowledge or skill, as
well as low interest in training and
low perceived relevance to practice,
were around issues of gangs,
gay/lesbjan/bisexual/transgender
youth, HIV/AIDS, and counseling
about a positive pregnancy test.
Also, PNPs identified the lack of
resources appropriate for adolescent
referrals as the greatest barrier to
working with this population.
Discussion: PNPs assessed their
lowest competencies in some of the
areas that present the greatest threats
to adolescents’ health and wellbeing. These deficits suggest needed
curricular shifts in entry-level and
advanced-level preparation of PNPs,
as well as new priorities for continuing education.
j Pediatr Health Care. (1999). 73,
183-I 90.
BSN,
MN,
Evans,
RN,
PhD,
Debra
Berglund,
PhD,
Marjorie
MSW,
MS,
RN,
Ireland,
PhD,
MPH
for millions of young people in the .United States, the generally healthy
life stage of adolescence is burdened by preventable health problems and
poor health habits and is sometimes cut short by death (Green, 1994). Since
the 195Os, patterns of adolescent morbidity and mortality have shifted from
the effects of communicable disease to problems with social and environmental factors (Bearinger & Blum, 1987). In the span of a month, 930 US
teenagers, ages 15 to 19 years, die from unintentional injury, homicide, and
suicide; by comparison, only 10 teenagers per month die from infectious diseases such as pneumonia, influenza, and AIDS (calculations based on a report by United States Department of Health and Human Services, 1996). Suicide has increased among young people ages 10 to 19 years, with firearms
being the most common means of committing suicide (Sells & Blum, 1996).
Peggy Nerdahl is a School Nurse in the St Paul Public Schools, St Paul, Minn, and a master’s student in
Graduate Studies in Adolescent Nursing, School of Nursing, University of Minnesota8 Minneapolis.
Debra Berglund is a Pediatric Nurse Practitioner for the Minneapolis Department of Health School-Based
Clinics, Minneapolis, Minn. At the time of the completion of this research, she was a master’s student in
Graduate Studies in Adolescent Nursing, School of Nursin g, University of Minnesota, Minneapolis.
Linda H. Bearinger is an Associate Professor and Director of the Center for Adolescent Nursing Leadership,
School of Nursing, and Nursing Faculty for the Division of General Pediatrics and Adolescent Health, Medical
School, University of Minnesota, Minneapolis,
Elizabeth M. Saewyc is the Manager
Medicine, University of Washington,
of Nursing, University of Minnesota,
of Clinical Services for the Young Women’s Clinic, Division of Adolescent
Seattle. She is a consultant to the Center for Nursing Leadership, School
Minneapolis,
Marjorie Ireland is a Research Associate for the Division
School, University of Minnesota, Minneapolis,
of General
Pediatrics and Adolescent
Theora Evans is an Assistant Professor in the Division of General Pediatrics and Adolescent
School, and School of Social Work, University of Minnesota, Minneapolis.
Health, Medical
Health, Medical
Supported by grants MCJ279185 (Graduate Studies in Adolescent Nursing), MCJ 00985 (Adolescent Health
Training Program), and MCJ273AO3-03-O
(PH Nutrition Training Program) from the Maternal and Child Health
Bureau, (Title V, Social Security Act), Health Resources and Services Administration,
Department of Health and
Human Services, VVashington, DC; grant No. 448.CCU513331
(Teen Pregnancy Prevention Research Center)
from the Centers for Disease Control and Prevention, Atlanta, Ga; and grant No. lMCJ27ROO2.02 (Project
Connect) from the Institute for Health & Disability, University of Minnesota, Minneapolis.
Reprint requests: Linda Bearinger, PhD, Center for Adolescent Nursing Leadership, School of Nursing,
University of Minnesota, 6-l 01 Weaver Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455.
Copyright
0 1999 by the National Association
0891-5245/99/$8.00
+ 0
of Pediatric Nurse Associates
& Practitioners.
25/l/96769
183
ORIGINAL ARTICLE
Given recent trends, researchers predict
that firearms will become the leading
cause of injury deaths among youth in
the United States by the year 2003,
superseding
deaths resulting
from
motor vehicle accidents (Kiter, Vassar,
Harry & Layton, 1995).
Likewise, risk-taking behaviors and
the social and economic contexts within which they occur underlie most adolescent morbidities.
Risky behaviors
that threaten the health of young people include alcohol use, tobacco and
marijuana
use, and unsafe sexual behaviors such as early onset of sexual
intercourse and inconsistent use of condoms. Such unsafe practices result in
high rates of sexually transmitted diseases, rising rates of pregnancy among
girls younger than 15 years of age,
and an increasing incidence of fatherhood among adolescent boys (Sells &
Blum, 1996). Moreover, large numbers
of young people experience threats to
their health in adulthood
as a consequence of choices made during adolescence. As examples, most adults who
smoke began using cigarettes before
age 18 years (Hardy Haven & Ham-ran,
1996). AIDS cases are overrepresented
in the 20- to 29-year-old
age group;
most of these cases were acquired during adolescence (Sells & Blum, 1996). In
addition, pregnancies
during the teen
years can lead to lifelong disadvantage
for both the parents and their children
(Maynard, 1996).
Clinicians and researchers alike are
aware that the distribution
of mortality
and morbidity
is not equally distributed across racial/ethnic
groups in the
United States. Whereas the death rate for
US adolescents has decreased for most
teenagers, it has increased for African
American
male teenagers. Homicide
rates are 8 times higher among African
American men than among European
American men and are 4 times higher
among African American women than
among European American
women.
Hispanic and American Indian youth
have the highest rates of reported suicidal ideation and attempted suicide.
Reported alcohol use is highest among
European American youth, who also report the highest prevalence
of daily
smoking. The pregnancy rate for teens
of color is almost double that of White
teens. African American and Hispanic
youth have higher rates of AIDS cases
among young people ages 13 to 24 years
184
Volume
13 Number
4
Nerdahl et al.
than do other racial/ethnic groups (Sells
& Blum, 1996). Cultural variation alone
does not explain these differences; an array of historical, economic, environmental, peer, and social factors are at work
(Dash, 1996; Schorr & Schorr, 1989).
The shift to social causes of ill health is
evident Risky behaviors increasingly
threaten the health and well-being
of
this age group. As health care providers,
the following
question must be asked:
What role can we play in influencing
health behaviors of teenagers and improve their health outcomes? Agrowing
number of studies indicate that providers can influence positive change. For
instance, Hingson, Strunin, and Berlin
(1990) found that teenagers who discussed AIDS with a health care provider
were more likely to use condoms. Likewise, Middleman,
Binns, and Durant
(1995) found that physicians who had
completed an adolescent rotation during residency were more likely to screen
for substance use, depression/suicidal
ideation, violent behavior, and nutritional issues, all of which are associated
with poor health outcomes for youth.
Nurse practitioners
(Nl’s) have repeatedly demonstrated
their ability to
deliver quality cost-effective care with an
emphasis on health promotion
(Dunn,
1993a). Brown and Grimes (1993) found
that nurses providing primary care offered more health promotion
services
than did physicians. NI?s practice in settings frequented by adolescents, such
as schools, school-based or communitybased clinics, child care centers, and juvenile detention centers, as well as traditional practice settings (Cohen & Juzczak,
1997; Dunn, 1993a; Grey & Flint, 1989). In
response to the changing demographics
of clients, nurses have heightened awamness of the need for cultural sensitivity in
health care. In sum, NPs are well suited
to address the complex health problems
of underserved adolescents because they
have been educated to provide culturally appropriate
care around preventable health problems, particularly health
problems resulting from risky behaviors, and they are apt to practice in settings in which health care is accessed by
teenagers.
Do pediatric
nurse practitioners
(PNPs) agree that they are well suited
to meet the most common health problems of teenagers? In 1986, a national
educational
needs assessment survey
was conducted that included a sample
of nurse members of 3 nursing organizations, one of which was the National
Association of Pediatric Nurse Associates and Practitioners
(NAPNAP).
Of
the 112 NAPNAP
respondents,
44%
cited lack of training as the most common barrier to managing adolescents
(Bearinger, Wildey, Gephart, & Blum,
1992). Despite the fact that almost half
of the 112 NAPNAP
respondents indicated a lack of adolescent training, 48.2%
had an adolescent
client population
comprising
10% to 50% of the nurse’s
practice population.
Inadequate
training regarding health problems and concerns related to adolescent endocrinology, homosexuality,
and mental health
issues was most frequently cited. This
finding is cause for concern, especially
because clinical research has documented that teenagers rarely confide health
issues and concerns to health care providers, particularly
regarding sensitive
issues such as sexuality and sexual orientation, if clinicians do not inquire
about such issues (Blum, Buehring, Wunderlich, & Resnick, 1996). Consequently,
clinicians’
failure to assess certain health
concerns may mean that adolescents in
need of intervention
may not be noticed
and served. For example, bisexual and
homosexual
youth who are at heightened risk for a variety of psychosocial,
emotional, and physical problems related to the stigma that accompanies a
nonheterosexual
orientation are among
those least apt to confide their concerns
to clinicians who do not inquire about
them (Bidwell & Deisher, 1991; West &
Remafedi, 1988).
In contrast to the deficits described
above, in the study by Bearinger et al.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
Nerdahl et al.
ORIGINAL ARTICLE
(1992), NAPNAP
members felt best
prepared to provide adolescent services
for acne, growth and development
issues, common recurring acute illness,
and obesity. Nearly two thirds of NAPNAP respondents
believed they had
sufficient preparation
to care for family
planning issues. Similarly, about half of
the respondents in a national survey of
NAPNAP
members by Grey and Flint
(1989) reported being involved in family planning services.
The purpose of this study was to
examine the self-perceived
competenties of PNl’s in addressing
the health
care needs of adolescents. With this
understanding,
nursing education programs can be better designed to enhance PNPs skills in managing adolescent health care issues. Three questions
were addressed:
(a) Among
PNl’s,
what are their self-perceived
levels of
knowledge
and skill around common
concerns and health needs of adolescents, their perceptions of the relevance
of these issues to their practice, and
their interest in further training in these
areas? (b) What do PNPs perceive as
barriers
and attractions
to working
with adolescents? (c) What continuing
education methods do PNPs find most
useful?
METHODS
This study examined data from a 1997
multidisciplinary
national
survey of
health care providers
that focused on
self-assessed competencies in addressing key health concerns and issues of
adolescents. The survey of nurses was
part of a larger study involving 5 disciplines (nurses, nutritionists, physicians,
psychologists, and social workers [N =
46001) to determine
education
and
training needs across and within each
discipline
in the area of adolescent
health.
After Institutional
Review Board approval of study protocols, a sample of
1000 nurses was randomly
selected
from nurse members of NAPNAP, the
National Association of School Nurses,
and the American Public Health Association. Questionnaires
were mailed in 2
rounds during January and February
1997. The response rate among nurses
was 63.7%. Of the 637 questionnaires returned, 275 were either members of
NAPNAP
or reported that they were
certified as a PNP, although they were
members of one of the other two na-
JOURNAL
OF PEDIATRIC
HEALTH
CARE
tional nursing organizations.
Questionnaires from respondents who did not
work with adolescents were eliminated
from this analysis, leaving a usable final
sample of 257 PNI’s.
The questionnaire
used in this study
was developed by an interdisciplinary
group of adolescent
health experts,
based on an instrument developed for
a national multidisciplinary
survey of
health clinicians around competencies
in adolescent health (Bearinger et al.,
1992). The questionnaire
was reviewed
by an outside panel of experts across
disciplines
and pilot tested with approximately
50 clinicians from the 5
disciplines.
In addition
to including
items about self-assessed competencies
in 28 health issues and care needs most
commonly
affecting adolescents,
the
instrument
included
items regarding
respondents’ highest level and recency
of education, areas of specialty and certification, and practice-setting
characteristics. Respondents were also asked
to identify barriers and attractions to
working
with youth. The number of
barriers and attractions identified
by
respondents were evaluated in relation
to the percentage of adolescents in the
population
served, years worked with
adolescents,
recency of the respondents’ highest degree, and the respondents’ highest educational level.
Self-perceived
knowledge/skill
and
the respondents’ interest in training for
each of the 28 health issues were rated
on a 3-point Likert scale (low = 1; moderate = 2; high = 3). Respondents
also
indicated relevance to practice of each
of the 28 issues. A composite knowledge/skill
scale was constructed with
all 28 health issues to evaluate its correlation with recency of education, level
of highest degree, number of barriers
and attractions to working with adolescents, percentage of adolescents in the
practice population,
practice setting,
and interest in training. A similar composite scale was constructed for interest
in training.
Ethnocultural
issues in
practice were explored through a composite scale for knowledge/skill
and
interest in training in 2 specific areas:
cultural sensitivity and integration
of
ethnocultural
issues into practice (low
= 1; moderate = 2; high = 3).
In addition,
the survey asked respondents to identify their knowledge,
skill level, and interest in training for
18 topics related to research, adminis-
TABLE 1 Characteristics of
survey respondents*
No. (%I
PNP characteristic
Highest level of education
completed
Non-degree training
for certification
Masters
Doctorate
Certified in a specialty
Area of certification
Pediatrics
Family
Adult nursing
School nursing
Other
Percentage of clients who
are adolescents
None
<IO%
IO%-25%
2 6%-5 0%
>50%
Years worked with adolescents
o-5
6-l 0
11-15
16-25
226
*Percentages
55 (22)
160
(64)
15 (6)
253 (92)
212 (92)
6 (3)
1 W)
t3 (4)
4 (2)
18 (71
63 (23)
122 (45)
46 (17)
27
@I
64
63
45
82
15
(24)
(23)
(17)
(31)
(6)
are adjusted for missing responses.
tration, community
organizing,
and
more specific skills such as public
speaking
and communication
with
adolescents. Again, the items used the
3-point Likert scale.
Finally, a 4-point Likert scale asked
respondents
to indicate usefulness of
various continuing education methods.
Attendance at national conferences was
compared
in relation to knowledge,
skill level, and interest in training pertaining to the 28 adolescent health concerns.
Simple descriptive
statistics were
used to describe the data. For categorical data, counts and percentages were
used; for continuous data, means, standard deviations, and ranges were used.
Pearson’s correlation coefficients measured associations
between
knowledge/skill
levels and other variables.
The one-sample t test was used to evaluate whether the estimate of the correlation coefficient was different from
zero.
July/August 1999
185
ORIGINAL
ARTICLE
TABLE
Z! PNP practice
(N = 257)*
Practice
setting
Nerdahl
settings
TABLE
3 PNPs reporting
low knowledge
and’skill
issues and moderate/high
interest in training*
No. (%I
low
Adolescent
Population of community
C25,ooo
49 (20)
25,001-100,000
58 (24)
lOO,OOl-1
million
lOZ(41)
>l million
38(15)
Place of employment
Private practice
102(63)
Hospital based
63 (231
School based
39 (14)
Public health
34 (12)
HMO/prepaid
group
28(11)
Academic setting
25 (91
Juvenile justice/corrections
6 (2)
Children and family services
6 (2)
Home based
5 (2)
Residential setting
4 (2)
Community mental health
4 (2)
Child protective services
2 (<I)
Other
47 (17)
*Percentages
areadjusted
for missing respses.
RESULTS
Demographics
Characteristics of the respondents
are
shown in Table 1. Of the 70% of respondents (n = 175) with advanced degrees,
the majority were masters prepared.
Nearly all PNI’ respondents were specialty certified; most were certified in pediatrics (92%), with a few certified in related areas. Approximately
90% of the
nurses surveyed had completed their
formal nursing education within the
past 20 years, with 35% having graduated within the past 5 years. Considerable variation was found in the number
of years respondents had worked with
adolescents. Six percent had worked
with adolescents longer than 26 years,
33% between 16 and 25 years, and 25%
between 6 and 10 years. Of those who
worked with adolescents at least some
of the time, nearly 75% of the respondents indicated that adolescents comprised one fourth or more of their patient
population. For 8% of PNP respondents,
teenagers constituted more than half of
their client population.
As shown in Table 2,57% of the respondents
practiced in communities
with populations
larger than 100,000.
Nearly half of respondents
worked in
private practice (37.1%) or a health
186
Volume13
Number4
health
issue
Gay/lesbian/bisexual/transgender
issues
Gang-related activities
Counseling re: HIV/AIDS
Foster care/shelters/homelessness
Delinquency/violence
prevention
Mental retardation
Counseling re: adoption/abortion
Depression
Ethnocultural issues
Smoking cessation
Suicide risk
Eating disorders
Physical disabilities
Learning disorders
Substance abuse
Sexual abuse
Attention deficit disorder
Adolescent pregnancy
Psychosomatic complaints
Counseling teens with family problems
Physical abuse
Behavioral problems
Sexually transmitted disease
Sex education, contraception
Chronic physical illness
Counseling after negative pregnancy tests
Adolescent parenting
Obesity
*Percentagesxe
adjustedformissing
knowledge/skill
No. (%)
181
175
(74)
(72)
in adolescent
health
Interested
in training
No. (%)
145(61)
149(62)
124(51)
142
141
161
(60)
(61)
(69)
111
191
(81)
(46)
109 (45)
135 (58)
104 (43)
94 (3 9)
149(64)
197 (84)
87 (36)
82 (34)
83 (34)
78(33)
78(32)
77(31)
76(31)
70 (29)
63 (26)
60 (25)
61 (25)
55 (22)
49 (20)
49 (20)
48 (20)
48 (20)
48 (19)
47 (19)
37 (15)
28(12)
et al.
183 (77)
171 (72)
173 (75)
170
(74)
175 (74)
190 (80)
184
192
180
171
190
(79)
(82)
(76)
(73)
(80)
212 (88)
195 (84)
210 (88)
183
(78)
187 (79)
191 (80)
168(72)
204(85)
194
(82)
responses.
maintenance organization (HMO)/prepaid group setting (10.2%). Other respondents practiced in hospital-based
settings (23%), school-based
settings
(14.2%), or public health settings (12.4%),
and the remaining
few practiced in
residential, home-based, child protection, juvenile justice, community mental health, and child or family service
settings.
Almost half of the respondents reported working with predominantly
nonWhite adolescent clients (ie, more than
50% in their practice population). Half of
the respondents reported that at least
10% of their practice population
were
African American; almost one third had
practice populations
with at least 10%
H&.panic/Latino-American
clients; 1 in 7
had 10% or more biracial clients; and 1 in
10 had 10% or more Asian American/
Pacific Islanders in their practice populations. Approximately
3% pravided ser-
vices in practice settings where at least
10% of clients were Native American/
Alaskan Natives.
Knowledge and Skills in
Adolescent Health
The majority of respondents
reported
high or moderate knowledge
and skill
in addressing issues related to obesity
adolescent parenting, chronic physical
illness, safe sex and contraception,
sexually transmitted
disease, behavior
problems, physical abuse, psychosomatic complaints, and adolescent pregnancy. They also reported moderate or
high knowledge and skill in counseling
adolescents with family problems and
addressing intervention
needs subsequent to negative results of a teen’s
pregnancy test.
In comparison with areas of moderate or high competence, the majority Of
IYIPs identified 4 areas in which they
JOURNALOF
PEDIATRICHEALTHCARE
!%I
ORIGINAL ARTICLE
Nerdahl et al.
TABLE 4 Factors correlated with knowledge/skill
and interest in training
T/UlI
5 strategies for
continuing education (N = 257)*
about adolescent issues (N = 257)
Variables
Knowledge/skill
level
correlated
with:
Interest
in training
No. of attractions
to working
with adolescents
% of adolescents
in practice
(2 = <I 0%;
3 = IO%-25%;
4 =26%-50%;
5 = >50%)
Ethno-cultural
knowledge/skill
and interest
in training
correlated
with:
% of African
(1 = 0%;
American
2 = <lo%;
4 = 26%-50%;
% of Hispanic
2 = <lo%;
teens in practice
3 = IO%-25%;
Range
Mean
SD
28-74
28-84
O-4
2-5
50.80
57.40
2.20
3.09
10.80
14.60
2-12
8.01
I .90
l-5
2.90
1.22
.2ot
l-5
2.32
1.90
.17-t
1.00
0.87
Pearson’s
r
.30*
.36*
.22*
5 = >50%)
Interest
No.
in training
of attractions
correlated
to working
with:
with
adolescents
28-84
o-4
57.40
2.20
14.60
1 .oo
education
.32*
activity
Regular
attendance
at
national
conferences
Methods
respondents
reported
hands-on
experience
Large conferences
Lectures
Coursework
for credit
Reading
journals
or
research
papers
Self-study
materials
Teleconferencing
or
interactive
TV
Internet
materials
or courses
*Ps ,001.
tP<
*Percentages
-05.
perceived low knowledge
or skill (as
shown in Table 3); these areas included
addressing issues and needs of young
people who are gay/lesbian/bisexual/
transgender
(74%), youth who are in
gangs (72%), clients with HIV/AIDS
(62%), and youth who are homeless or
receiving foster care (51%). The next most
frequently cited areas of low knowledge
and skill were around issues and care
needs for delinquent
or violent youth
(46%), young
people with mental retardation (45%), pregnant adolescents considering abortion/adoption
(43%), and
depressed adolescents (39%). PNPs were
also interested in training, with more
than 70% indicating a high or moderate
level of interest in 22 of the 28 adolescent
health issues and care needs (also shown
in Table 3).
Correlates
levels
of Knowledge
and Skill
A positive correlation existed between
overall self-perceived
knowledge
level
and interest in training; that is, respondents with higher knowledge and skill
levels also had higher levels of interest
in training (r = .30, P 2 .OOl, Table 4).
Likewise, respondents with lower ability had lower interest in further training. For instance, 85% of respondents
reported moderate or high knowledge
about adolescent parenting, and 90% of
these “knowledgeable”
practitioners
were highly or moderately interested in
JOURNALOFPEDIATRICHEALTHCARE
training. In comparison, 74% of respondents stated that they had low knowledge or skill in counseling gay, lesbian,
bisexual, or transgender youth, but just
over half (55%) of the “low knowledge” respondents had high or moderate interest in further training around
these issues. Likewise, 62% of respondents stated that they had low knowledge and skill in counseling youth with
HIV/AIDS,
yet only half of the “low
knowledge”
respondents were moderately or highly interested in receiving
further training regarding counseling
youth with HIV/AIDS.
Two other areas
of knowledge/skill
deficits showed
correspondingly
low interest in training: gang-related
activities (72% perceived low knowledge and skill, and of
those, only 51% had moderate or high
interest in training);
and counseling
pregnant adolescents about adoption
and abortion
(42% had low knowledge/skill,
and of those, only 44% had
moderate or high interest in training).
For all the other 28 health concerns,
interest in training was stronger than
was the apparent knowledge
deficit in
that area, that is, the proportion
of
those interested in training was greater
than the proportion
who rated themselves low in knowledge and skill.
Relevance to current practice directly
covaried with interest in training and
knowledge level. In other words, if respondents identified
an issue or con-
No. (%)
131
(56)
as “very
useful“
Small conferences
Workshops
with
5 = >50%)
teens in practice
(I = 0%;
3 = IO%-25%;
4 = 26%-50%;
Continuing
~~~adjustedformissing
215
199
(87)
(80)
153 (62)
138 (56)
135 (55)
124 (50)
81 (33)
56 (23)
42 (I 7)
responses.
tern as relevant to their practice, they
were more likely to be interested in
training and perceived a higher level of
knowledge
and skill in that area. For
the 14 lowest knowledge/skill
areas,
low relevance to practice was highly
correlated
with both low interest in
training and low knowledge
and skill
(t test statistics ranged from 3.52 to 8.20,
P 5 ,001). The 3 areas with the greatest
number
of low knowledge/skill
responses were also considered not relevant by more than half of respondents:
HIV/AIDS
(63%), gay/lesbian/bisexual/transgender
issues (59.8%), and
gang-related activity (53.5%).
As depicted in Table 4, higher perceived knowledge
and skill level was
moderately correlated with both higher
numbers of attractions to working with
adolescents (r = .36, P 2 .OOl), and a
greater proportion
of adolescents in the
practice (r = .21, P 5 .OOl), Higher interest in training was also moderately correlated with greater attractions to working with adolescents (r = .32, P 5 .OOl).
No significant correlations were found
between knowledge/skill
level and recency of education, levels of education,
traditional
practice setting (eg, private
practice or hospital-based)
versus nontraditional
practice setting (eg, schoolbased, public health, juvenile justice), or
number of identified barriers.
Wereas
experience working
with
adolescents correlated with skill level, so
July/August1999
187
ORIGINAL ARTICLE
too did experience with minority patients correlate with both skill level and
interest in training around ethnocultural
issues. Among respondents who had a
larger African American
or Hispanic
population in their practice, a moderate
positive correlation
was found with
knowledge, skill, and interest in training
around cultural issues (African American, r = .21, P < .05; Hispanic, r = .17, P <
.05, Table 4). Overall, 76% of respondents
considered ethnocultural issues relevant
to their practice. Thirty-six percent of respondents reported seti-perceived low
knowledge or skill around ethnocultural
issues, and 76% were moderately
or
highly interested in training. Forty percent of respondents reported high interest in developing further skill in cultural
sensitivity.
In addition to cultural issues, I’NPs reported high interest in developing various leadership skills in adolescent health,
communicating
with adolescents (57%),
health promotion strategies (56%), working with families (47%), psychosocial
needs of adolescents (46%), adolescent
development
(41%), teaching (33%), de
veloping needs assessments (32%), and
advocacy (31%). At least half of respondents identified low knowledge or skill
in the following
areas: grant writing
(77%), program evaluation (65%), pmfessional writing (61%), coalition building
(57%), conducting research (57%), and
community organizing (49%).
Continuing
Education
Among the respondents, 3 methods of
continuing
education were preferred
(Table 5): (a) attending small conferences, (b) workshops
with hands-on
experience, and (c) large conferences.
More than half of the nurses reported
that they regularly attend national conferences (56.2%). Half of those attending national conferences also regularly
attend nurse practitioner
association
conferences. No significant differences
were found in self-perceived
knowledge, skill level, and interest in training
between those who attend nurse practitioner national conferences and those
who do not attend these conferences.
LIMITATIONS
Limitations
of this study should be
considered when weighing the study‘s
findings. As with any survey methodology, an assumption
was made that
self-reported knowledge and skill levels
188
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Nerdahl
constitute a valid indicator of clinicians’
competencies. In addition, closed-ended
questions do not provide an opportunity to obtain additional
information
that may add meaning to interpretation
of data. Also, although
face validity
was established, test-retest would have
strengthened the instrument further.
DISCUSSION
With growing awareness of the changing health care needs of adolescents
comes the realization that health care
providers may not be adequately prepared to address these needs. It is encouraging
that 75% of PNPs in this
national study who serve adolescents
believed they were moderately or highly skilled in managing key adolescent
health issues and care needs including
obesity, adolescent parenting, chronic
physical illness, safe sex and contraception, sexually transmitted
disease, behavior problems, physical abuse, psychosomatic complaints, and adolescent
pregnancy. The respondents
also reported moderate or high skill in counseling adolescents with family problems
and adolescents who have negative results of a pregnancy test. However, areas of deficiencies also were evident.
The study found 12 of 28 areas in which
one third or more of respondents identified low knowledge
and skill. These
areas included
issues or health care
needs of gay/lesbian/bisexual/transgender youth; youth in gangs or who
are involved in delinquency
and violence; youth with HIV/AIDS;
youth
who are homeless, live in shelters, or
receive foster care; young people with
mental retardation;
pregnant
adolescents making adoption or a.bortion decisions; youth who are depressed and
who are at risk for suicide; and young
people who seek smoking cessation
support. Finally, more than one third of
et al.
respondents (36%) reported low knowledge and skill in addressing ethnocultural issues.
PNPs’ self-reported
abilities in conjunction with their interest in further
training in 4 other substantive areas are
a particular
basis for concern. These
areas include the provision of care for
youth in gangs, delinquency
and violence prevention,
counseling
youth
with HIV/AIDS,
and counseling gay/
lesbian/bisexual/transgender
youth.
The heightened concern is that, despite
low perceived
knowledge
and skill,
low interest in additional
training in
these areas was also reported. Furthermore, for 3 of these issues, that is, gay/
lesbian/bisexual/transgender
issues,
HIV/AIDS,
and gang involvement
(all
of which were rated among the lowest
in knowledge and skill), more than half
of the respondents
did not consider
these issues to be,relevant to their practice. Given that all the I’NI’ respondents included
in the study sample
reported that they provide care to adolescents, it cannot be argued that these
issues are not present in their practice
populations.
National
data indicate
that within
adolescent
populations,
these issues are indeed relevant and
affect the health and well-being
of
young people across boundaries
of
geography, race, ethnicity, and socioeconomic status (Resnick et al., 1997).
The I’NP respondents who found these
issues to be irrelevant to their practice
instead may be unaware of these concerns or health threats among their
teenaged clients. Is this perception,
then, related to the aforementioned
hesitancy of teenagers to confide in
practitioners who do not broach certain
issues, particularly
sensitive issues,
with their clients? If so, providers may
erroneously
assume that these issues
do not affect the well-being
of their
adolescent clients and may be overlooking critical health care needs.
In spite of these concerns about
PNPs’ self-assessed knowledge
and
skills, interest in further training, and
perceptions
about issues relevant to
practice, has nurses’ ability to work
with adolescents improved in the past
decade? Compared with the national
survey of nurses conducted by Bearinger et al. (1992) more than a decade
ago, an increase of 20% in perceived
knowledge and skill around adolescent
reproductive
issues has been reported
JOURNAL
OF PEDIATRIC
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iFb
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Nerdahl et al.
ARTICLE
by PNP respondents, which is encouraging. This finding does not hold true
for all 28 health issues, however. For
example, almost half of the PNl’s in the
present survey reported a low level of
skill and one third reported low interest in training around pregnancy counseling related to adoption and abortion.
The majority of respondents
in this
national survey perceived barriers to
working
with adolescents. The most
frequently reported barrier was a lack
of community
resources for referral of
adolescents. This barrier is important to
consider given that almost half of the
respondents reported low knowledge
and skill regarding
community
organizing, and more than half reported
low knowledge
and skill regarding
coalition building. Because one-on-one
programs
and services have little
chance of success in changing
the
lifestyles of adolescents
involved
in
gangs and illegal drug distribution
(Elliott, 1993), knowledge
and skill in
community
organizing
and coalition
building
become essential for nurses
who want to counter these threats to
adolescent health.
Although
almost half of respondents
identified lack of community resources
as a barrier, only 15.5% of respondents
reported that a lack of training in adolescent health constitited
a barrier for
them. This percentage is significantly
less than the 44% of the NAPNAP
respondents who reported lack of training to be a barrier in the 1986 study by
Beartiger et al. (1992). Additional
barriers to working with adolescents may
exist that are not easily identified and
were not articulated in this study.
The most commonly reported attractions to working with adolescents cited
by respondents were that they enjoyed
talking and working with adolescents
and they find adolescent health interesting. This finding is encouraging
and
reinforces findings of earlier studies,
which indicated that health care providers are not opposed to working with
adolescents and that, in reality, most
health care providers
enjoy working
with this population
(Bearinger
&
Blum, 1987; Story & Blum, 1988).
CONTINUING
EDUCATION
How, then, can nurses proceed in improving their competencies in deficit areas? I’NPs are a group highly motivated
to learn about the needs of adolescents,
JOURNAL
OF PEDIATRIC
HEALTH
CARE
with nearly 75% in this study reporting
moderate or high interest in training
around the majority of adolescent issues. This interest is further supported
by the finding that more than half of respondents attend national conferences
routinely. Continuing
education
is a
high priority for members of NAPNAP;
98% participate in continuing education
programs, and 42% attend the mual
national NAPNAP
conference (Dunn,
1993b). Because continuing education is
essential for maintaining
certification,
and given that 92% of respondents in the
present study were certified in a specialty it may be assumed that the remaining respondents obtain continuing
education in ways other than national
conferences.
affect the health and wellbeing of adolescents.
What are the preferred
methods of
learning among nurses? In the 1986
national survey of nurses from 3 organizations, nurses preferred workshops
with hands-on experience, followed by
small workshops
with opportunities
for discussion among peers. Self-study
material was cited as the least preferred
method of learning (Bearinger et al.,
1992). In the present study, survey
respondents likewise preferred handson experience in large or small group
settings. Hands-on experience for practitioners could include but is not limited to enhancing communication
skills
through the use of adolescent actors as
simulated patients, particularly
around
the topics of gangs, sexual orientation
issues, sexually transmitted
diseases
(including HIV/AIDS),
and counseling
after a positive pregnancy
test, plus
practice in assessing cultural perspectives and providing
culturally
competent care. This study also demonstrates
a need for building skills in commtity
organizing
and developing
coalitions
to address the complex needs of adolescents, with specific information
about the roles PNF’s can take in these
processes.
CONCLUSION
Given a trend of increasing social and
environmental
causes for adolescent
morbidity
and mortality,
a growing
proportion of youth of color in the population, and the multifaceted
issues
that face adolescents and their PNP
providers, the demand on entry-level,
advanced-level,
and continuing education is high. Moreover, PNPs must continue to improve their cultural competence in working
with young people.
Education needs to address the key role
that nurses can play in the lives of their
adolescent gay, lesbian, bisexual, and
transgender
clients, youth with HIV/
AIDS, adolescents involved
in gangs,
and youth who are pregnant and considering their options. PNPs must also
acquire the skills of collaboration
to
enable them to work with others in
developing
community
solutions
to
complex
social and environmental
issues that affect the health and wellbeing of adolescents. Through formats
of small and large conferences
and
hands-on workshops,
particularly
national PNP meetings, PNPs can be better prepared
to address adolescent
needs at public policy and community
levels, in addition to being better prepared to intervene
with individuals
and families.
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