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Strengthening PNP Curricula in Mental/Behavioral Health and Evidence-
based Practice
Article  in  Journal of Pediatric Health Care · March 2010
DOI: 10.1016/j.pedhc.2009.01.004 · Source: PubMed
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ARTICLE
Strengthening PNP Curricula
in Mental/Behavioral Health
and Evidence-based Practice
Bernadette Mazurek Melnyk, PhD, RN, CPNP/NPP, FAAN, FNAP,
Elizabeth Hawkins-Walsh, PhD, RN, CPNP, Michelle Beauchesne, DNSc,
RN, CPNP, FNAP, Patricia Brandt, PhD, RN, ARNP, Angela Crowley, PhD,
APRN, PNP-BC, FAAN, Myunghan Choi, PhD, MPH, RN,
& Edward Greenburg, PhD
ABSTRACT
Introduction: The incidence of mental health/behavioral and
developmental problems in children and teens is escalating.
However, many primary care providers report inadequate
skills to accurately screen, identify, and manage these prob-
lems using an evidence-based approach to care. Addition-
ally, educational programs that prepare pediatric nurse
practitioners (PNPs) have been slow to incorporate this con-
tent into their curriculums.
Methods: The purpose of this project was to implement and
evaluate a strengthened curriculum in 20 PNP programs from
across the United States that focused on: (a) health promo-
tion strategies for optimal mental/behavioral health and de-
velopmental outcomes in children, and (b) screening and
evidence-based interventions for these problems. An out-
comes evaluation was conducted with faculty and graduating
students from the participating programs along with faculty
and students from 13 PNP programs who did not participate
in the project.
Results: Participating schools varied in the speed at which
components of the strengthened curriculum were incorpo-
rated into their programs. Over the course of the project, fac-
ulty from participating programs increased their own
knowledge in the targeted areas and reported that their stu-
dents were better prepared to assess and manage these prob-
lems using an evidence-based approach. Although reports of
screening for certain problems were higher in the graduating
students from the participating schools than the non-partici-
pating schools, the overall use of screening tools by students
in clinical practice was low.
Discussion: There is a need for educational programs to
strengthen their curricula and clinical experiences to prepare
students to screen for, accurately identify, prevent, and pro-
vide early evidence-based interventions for children and
teens with mental health/behavioral and developmental
problems. This project can serve as a national model for cur-
riculum change. J Pediatr Health Care. (2010) 24, 81-94.
KEY WORDS
Pediatric nurse practitioners, education, mental health,
evidence-based practice
Bernadette Mazurek Melnyk, Dean and Distinguished Foundation
Professor in Nursing, Arizona State University College of Nursing &
Healthcare Innovation, Phoenix, AZ.
Elizabeth Hawkins-Walsh, Clinical Associate Professor, Director
of DNP & PNP Programs, School of Nursing, Catholic University of
America, Washington, DC.
Michelle Beauchesne, Associate Professor, Northeastern
University School of Nursing, Boston, MA.
Patricia Brandt, Professor, University of Washington School of
Nursing, Seatle, WA.
Angela Crowley, Associate Professor, Yale University School of
Nursing, New Haven, CT.
Myunghan Choi, Research Assistant Professor, Arizona State
University College of Nursing & Healthcare Innovation, Phoenix, AZ.
Edward Greenburg, Statistician and Director, Data Laboratory,
Arizona State University College of Nursing & Healthcare
Innovation, Phoenix, AZ.
Funding for this project was provided by the Commonwealth
Fund. For further information about the educational resource tool
kit from this project, please contact Bernadette.Melnyk@asu.edu.
0891-5245/$36.00
Copyright Q 2010 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.pedhc.2009.01.004
www.jpedhc.org March/April 2010 81

The nature of childhood morbidity has changed con-
siderably in the past few decades with a substantial rise
in behavioral, developmental, and mental health prob-
lems (Evans & Seligman, 2005; Melnyk & Moldenhauer,
2006). Multiple factors have contributed to the escala-
tion in these types of problems, including changes in
the composition of families (e.g., divorce and single
parenting), school violence, high levels of parental con-
flict and psychopathology (e.g., maternal depression),
and the surge in technology, which has contributed to
a higher survival rate in low-birth-weight premature
infants with long-term developmental disabilities.
Despite the current prevalence of mental health, be-
havioral, and developmental problems in children, ed-
ucational programs that prepare primary care providers
(PCPs), such as pediatric nurse practitioners (PNPs) and
pediatricians, have been slow to incorporate the
knowledge and skills that graduates need to effectively
assess, intervene, and prevent these types of problems
using an evidence-based approach. This situation is un-
fortunate because PCPs are in a unique position to iden-
tify and manage common behavioral and mental health
problems in children and adolescents, as approxi-
mately 75% of these children are seen in primary care
settings (Williams, Burwell, Foy, & Meschan, 2006);
however, less than 25% of affected children receive
any treatment (American Psychological Association,
2006). Although the burden of assessing and treating
children and teens for mental and behavioral health
problems has largely fallen to PCPs, findings from
recent studies have supported that PCPs report inade-
quate knowledge of screening and early intervention
practices for these problems (Asarnow et al., 2005;
Horwitz et al., 2002; Melnyk et al., 2002; Melnyk et al.,
2003; Richardson et al., 2005).
In the national KySS (Keep your children/yourself
Safe and Secure) survey of more than 650 pediatricians
and PNPs from 24 states across the United States, the
health care providers answered, on average, fewer
than two thirds of the mental health/psychosocial
knowledge questions correctly (Melnyk et al., 2003).
Furthermore, approximately 40% of the providers re-
ported that they did not screen at all or only sometimes
for these problems in children. Almost half of the
providers reported that their professional education
programs prepared them ‘‘not at all’’ to ‘‘a little’’ to as-
sess and effectively intervene for these problems. This
finding is alarming, given that preventive and early in-
tervention strategies by pediatric health care providers
during young childhood could ameliorate the risk for
serious psychiatric illnesses in later years (Janicke &
Finney, 2003). Furthermore, in a survey of 24 PNP
program directors as part of a project to assess the im-
pact of an adapted version of a ‘‘Healthy Steps Work-
shop’’ on PNP students at Yale University,
approximately half of the program directors stated
that they believed new graduates may have difficulty
providing comprehensive counseling, especially to
families at risk for problems (Crowley & McGee,
2003). Additionally, another national survey of the con-
tent of 78 PNP programs indicated that content and
skills on psychosocial/behavioral health issues varied
widely and that screening tools and early evidence-
based interventions for these problems did not have
a clear presence in the curriculums (Hawkins-Walsh &
Stone, 2004).
To address the changing nature of pediatric morbid-
ities, a ‘‘Future of Pediatric Education Conference’’ was
sponsored by the Macy Foundation in June 2003. Rec-
ommendations from this Conference, which drew
more than 30 expert pediatrician and PNP faculty and
clinicians, were that given the high prevalence of men-
tal health/developmental/behavioral disorders among
well children, educational preparation should include
diagnosis and management by individuals or teams to
ensure parity between physical and mental health,
along with an understanding of and the ability to iden-
tify both risk and protective factors as well as critical
times that affect the trajectory of development (Hager,
2004).
In addition to the need to increase emphasis in PNP
programs on developmental and psychosocial screen-
ing, health promotion, and early interventions for the
current childhood morbidities, educational curricula
for PNPs also must include a strong emphasis on learn-
ing an evidence-based approach to clinical practice.
Evidence-based practice (EBP) is a problem-solving
approach to care that incorporates the conscientious
use of best evidence from well-designed studies, a clini-
cian’s expertise, and patient values and preferences in
making decisions about patient care (Melnyk &
Fineout-Overholt, 2005; Sackett, Straus, Richardson,
Rosenberg, & Hayes, 2000). Without current best evi-
dence, practice is rapidly outdated, often to the detri-
ment of patients. Despite the fact that one of the five
core competencies deemed necessary by the Institute
of Medicine’s Health Professions Education Summit is
employing EBP (Greiner & Knebel, 2003), only a small
percentage of health care providers are implementing
evidence-based care (Melnyk & Fineout-Overhol;Sack-
ett et al.). In recognition of the need to accelerate EBP,
the Institute of Medicine formed a roundtable on evi-
dence-based medicine and set the goal that, by 2020,
90% of health care decisions should be evidence based.
The major purpose of this project undertaken by the
Association of Faculties of Pediatric Nurses Practi-
tioners (AFPNP) was to implement and evaluate
a strengthened curriculum for PNPs that focused on
(a) EBP, (b) health promotion strategies to enhance
optimal mental/behavioral health and developmental
outcomes in children, and (c) comprehensive screen-
ing and early interventions for the current morbidities
of childhood (e.g., mental and behavioral health prob-
lems, overweight, and obesity), with an emphasis on
82 Volume 24 Number 2 Journal of Pediatric Health Care

young children, because optimal health in early child-
hood sets the stage for future health in later years.
METHODS
This project was an outcomes evaluation study of
a strengthened curriculum for nurse practitioner stu-
dents in 20 PNP programs across the United States.
Leadership for this project was provided by a team of
five faculty from the AFPNP (the first five authors of
this article) with a combination of expertise in curricu-
lum development and evaluation, EBP, developmental
and disabilities, mental health/psychosocial morbid-
ities, the Healthy Steps Program, and health promotion
interventions with parents and young children. These
five faculty members spearheaded the creation of the
strengthened curriculum for the project and mentored
PNP faculty from the 20 participating programs. The
participating programs were randomly selected from
a list of 85 PNP programs obtained from the Pediatric
Nursing Certification Board, including 10 randomly
selected programs from the top 20 ranked U.S. News
and World Report Schools of Nursing and 10 from the
remaining 65 schools that were not ranked in the top
20. All schools approached agreed to participate in
the project. Human subjects’ approval for the outcomes
evaluation study was granted by the research subjects’
review board at the first author’s University.
Year 1 of the Project
PNP faculty were informed of this proposal to
strengthen PNP curriculums in the areas of develop-
mental, behavioral, and mental health at the annual
meeting of the AFPNP in Dallas in March of 2004 and
were very enthusiastic about participation. The five-
member faculty leadership team convened a 2-day cur-
riculum institute planning meeting at the start of the
project. During this planning meeting, the agenda and
objectives for a faculty curriculum planning institute
were developed. Next, the leadership team convened
the first 3-day faculty curriculum planning institute
with PNP faculty from the 20 randomly selected
schools. The 3-day curriculum planning institute with
faculty from the 20 participating programs and the
five-member leadership team focused on the develop-
ment of a strengthened curriculum for PNP programs
that places a heavy emphasis on the teaching of screen-
ing skills for the early detection of developmental and
mental health/behavioral problems as well as evi-
dence-based preventive and early interventions to
enhance optimal outcomes in children and their fami-
lies. Participating faculty shared their own concerns
about inadequacies in their curriculum in the area of be-
havioral/mental health. Faculty had opportunities to
clarify which topic areas they currently included in their
curriculum and in which content areas they desired
a heavier curriculum emphasis. Presentations were
made by the leadership team faculty on the latest
evidence-based strategies for assessing and managing
common mental health/behavioral and developmental
problems. The end product of this first planning insti-
tute was a draft outline of the resources needed to
strengthen PNP curriculums in the targeted areas.
Approximately 4 months after the first faculty insti-
tute, the leadership team convened a second meeting
of the 20 participating faculty to complete the final
work on the strengthened curriculum. During this
meeting, lectures were conducted by the leadership
team on the previously identified areas of interest, in-
cluding (a) updated strategies for teaching EBP, (b)
teaching parental strategies to address early childhood
behavior concerns, (c) current approaches to compre-
hensive developmental assessments, including a new
focus on autism, (d) the application of a competency
approach to the curriculum, (e) cognitive behavioral
skills building techniques, (f) motivational interview-
ing, and (g) the incorporation of important components
of Healthy Steps into their programs. Additional ideas
for products needed by the faculty to strengthen their
curriculums also were generated.
In year 1, a baseline survey of all of the PNP graduates
from the 20 participating programs as well as a random
selection of 13 other PNP programs that were not par-
ticipating in this project was developed and conducted
to assess how well the graduates of the programs re-
ported that they were prepared in the specific target
areas that were to be addressed in the strengthened
curriculum (e.g., screening for development and psy-
chosocial problems, parent counseling, and popula-
tion-based health promotion interventions). Faculty
from the 20 participating schools and the 13 randomly
selected non-participating schools were asked to ad-
minister the survey to their graduating PNP students
in May of 2005, as well as to complete a faculty survey
that assessed their knowledge and beliefs in the tar-
geted areas along with how well they believed that their
students were prepared in these areas. These faculty
also identified whether and where in their curriculums
that this content was taught.
Student and faculty surveys
The student survey consisted of (a) demographic ques-
tions (e.g., age, race/ethnicity, and employment status),
(b) 18 questions that assessed their knowledge of psy-
chosocial, developmental, and mental/behavioral
health morbidities (e.g., parenting difficulties, depres-
sion, anxiety, behavioral problems, and developmental
disabilities) on a 5-point Likert scale from 1 (none) to 5
(a large amount), (c) 18 questions that asked how often
students screened for these problems on a 5-point
Likert scale from 1 (not at all) to 5 (always), (d) 15 ques-
tions that asked students whether they screened for
these items, (e) six questions that asked students how
satisfied they were with the amount of time and
guidance they provide to families on these issues on

a 5-point Likert scale that ranged from 1 (not at all satis-
fied) to 5 (very satisfied), (f) 12 questions on how well
prepared they believed they were to assess and manage
these issues on a 5-point Likert scale that ranged from 1
(not at all) to 5 (very well), (g) four questions that re-
lated to how well prepared they were for EBP from 1
(not atall) to 5 (very well),and (h)twoquestions related
to how well their program prepared them to practice as
a PNP on a 5-point Likert scale from 1 (not at all) to 5
(very well), and satisfaction with their PNP program
on a 5-point Likert scale from 1 (not at all) to 5 (very
much so). The final 14 questions asked about their con-
tinuing educational needs and whether completing the
survey raised their awareness of these issues and would
result in more frequent discussion and dialogue with
families about these issues.
A similar survey was developed for the faculty that
was comprised of (a) 16 knowledge questions about
the targeted areas on a scale from 0 (none) to 100
(extremely knowledgeable), (b) 34 items related to
their beliefs that the targeted areas need to be taught
to students, on a scale from 0 (not at all) to 100 (ex-
tremely), and (c) 12 items about how well they believed
their students were prepared in the targeted areas from
0 (not at all) to 100 (extremely well prepared). Addi-
tional questions asked the faculty about where certain
content was placed in their programs, as well as the
strengths and weaknesses of their programs.
Educational resource tool kit
Products were developed by the leadership team dur-
ing the first year of the project and collected in the
form of an educational resource tool kit that was dis-
seminated to enhance teaching and learning strategies
in the targeted areas (e.g., EBP, screening for mental
health/behavioral problems, and health promotion).
The resource kit included educational modules with
PowerPoint slides, DVDs of lectures for student educa-
tion, DVDs of clinical interviews with patients, a skills
checklist, clinical logs, Healthy Steps educational
videos, and the KySS Guide to Child and Adolescent
Mental Health Screening, Early Intervention and
Health Promotion (Melnyk Moldenhauer, 2006).
The programs began to strengthen their curricula and
integrate the products in the educational resource tool
kit that were disseminated to them in the first year of
the project. The five faculty mentors who comprised
the leadership team provided mentorship for the
PNP program faculty through telephone conferences
and e-mail exchanges. Regularly scheduled confer-
ence calls between the faculty mentors and their as-
signed faculty were conducted to ensure fidelity to
the revised curriculum and to assess successes as
well as implementation challenges. In addition, regu-
larly scheduled conference calls of the five-member
TABLE 1. Demographic information of PNP students from the 2004 and 2007 survey
2004 2007
Variable
Participating
students (n = 139)
Non-participating
students (n = 51)
Participating
students (n = 115)
Non-participating
students (n = 54)
Sex
Male 6 (4.3) 1 (2.0) 6 (5.2) 1 (1.9)
Female 133 (95.7) 50 (98.0) 109 (94.8) 52 (98.1)
v2
= .584; df = 1; P = .396 v2
= 2.737; df = 1; P = .077
Age (y)
22-30 93 (66.9) 25 (49.0) 83 (71.6) 33 (61.1)
31-40 29 (20.9) 18 (35.3) 19 (16.4) 14 (25.9)
41-50 11 (7.9) 4 (7.8) 12 (10.3) 6 (11.1)
51-60 6 (4.3) 4 (7.8) 2 (1.7) 1 (1.9)
v2
= 5.945; df = 3; P = .114 v2
= 2.342; df = 3; P = .504
Ethnicity
White/non-Hispanic 118 (84.9) 38 (74.5) 103 (89.6) 40 (74.1)
Other 21 (15.1) 13 (25.5) 12 (10.4) 14 (25.9)
v2
= 2.737; df = 1; P = .077 v2
= 6.774; df = 1; P = .010*
Marital status
Married/cohabiting 66 (47.8) 29 (56.9) 59 (51.8) 29 (53.7)
Other 72 (52.2) 22 (43.1) 55 (48.2) 25 (46.3)
v2
= 1.216; df = 1; P = .174 v2
= .056; df = 1; P = .472
Employment
Unemployed 27 (19.4) 5 (9.8) 19 (16.4) 4 (7.5)
Employed 112 (80.6) 46 (90.2) 97 (83.6) 50 (92.6)
v2
= 2.466; df = 1; P = .084 v2
= 2.535; df = 1; P = .085
*P .05.

leadership team were conducted to share information
from all of the schools that were participating in the
project as well as to suggest strategies for overcoming
challenges in the implementation of the revised
curriculum.
In the third year of the project, continued mentorship of
the faculty in the participating programs along with
monitoring of fidelity of the strengthened curriculum
was conducted by the leadership team. Graduates
from the participating and non-participating schools
in 2007 also were surveyed with the questionnaire com-
pleted by the 2004 graduates in year 1 of the project. In
the final year of the project, the leadership team met
again to discuss findings from the project and conduct
an outcomes evaluation.
DATA ANALYSIS
Data were analyzed using SPSS (Version 16). Demo-
graphic information for the PNP students and the use
of formal screening tools in the PNPs’ clinical practice
settings were analyzed using v2
tests. Students’ knowl-
edge of screening and intervening in clinical practice,
frequency of screening in clinical practice, level of
preparation to assess and manage psychosocial prob-
lems, further educational needs, and content being
taught in their programs were analyzed using t tests.
Faculty knowledge items and beliefs about content
needing to be taught in PNP programs from baseline
to follow-up also were analyzed by t tests. The level
set for statistical significance was .05.
FINDINGS
Demographic information for the graduating PNP stu-
dents from the baseline 2004 survey and the 2007
post-implementation survey are provided in Table 1.
In 2004, 139 graduates from the participating schools
and 51 graduates from 13 non-participating schools
completed the survey. In 2007, 116 out of 128 graduates
from 19 participating schools (a 90.6% response rate)
and 54 students out of 65 graduates from 12 non-partici-
pating schools (a 87.7% response rate) completed the
survey. Terms used in the analyses include wave (base-
line and follow-up) and group (participating and non-
participating). Baseline refers to data obtained from
the 2004 survey and follow-up refers to data obtained
from the 2007 survey.
Table 1 presents the demographic characteristics of
students from participating and non-participating
schools at baseline and at follow-up. The majority
were female, younger than 40 years of age, White/
non-Hispanic, and employed. In the 2007 follow-up,
approximately 90% of responding graduate students
in the participating schools were White/non-Hispanic
compared with 74.1% White/non-Hispanic in non-
participating schools (see Table 1).
In the 2004 baseline survey, no statistically significant
differences existed between the students from partici-
pating and non-participating schools on their reports
TABLE 2. Knowledge of screening and intervening for psychosocial/mental health problems in PNP
clinical practice from the 2004 and 2007 student surveys*
2004 2007
Variable
Participating
students (n = 139)
Mean SD
Non-participating
students (n = 51)
Mean SD
Participating
students (n = 116)
Mean SD
Non-participating
students (n = 54)
Mean SD
Depression 3.43 .90 3.64 .86 3.41 .79 3.28 .99
t = –1.474; df = 188; P = .142 t = .897; df = 168; P = .371
Anxiety 3.16 .88 3.39 .98 3.20 .80 3.13 .95
t = –1.550; df = 188; P = .123 t = .518; df = 168; P = .605
Violence 3.26 .86 3.31 .94 3.23 .81 3.17 1.00
t = –.317; df = 168; P = .751 t = .439; df = 168; P = .661
Sexual abuse/rape 3.32 .93 3.47 1.00 3.23 .88 3.24 .97
t = –.940; df = 188; P = .348 t = –.053; df = 168; P = .958
Substance abuse 3.51 .97 3.41 .96 3.42 .92 3.27 1.07
t = .421; df = 188; P = .674 t = .902; df = 168; P = .368
Eating disorders 3.43 .98 3.41 1.02 3.32 .80 3.18 .99
t = .998; df = 188; P = .886 t = .991; df = 168; P = .323
Stress and coping skills 3.35 v .88 3.54 .94 3.48 .92 3.33 1.00
t = –1.336; df = 188; P = .183 t = .979; df = 168; P = .329
Bullying 2.99 .98 3.13 .93 3.16 1.04 2.96 1.06
t = –.886; df = 188; P = .377 t = 1.135; df = 168; P = .258
ADHD 3.60 .91 3.72 .82 3.69 .95 3.41 1.09
t = –.821; df = 188; P = .413 t = 1.717; df = 168; P = .088
ADHD, Attention deficit hyperactivity disorder.
*Knowledge items are coded 1 = none to 5 = large amount.

of: knowledge regarding how to screen for and inter-
vene for mental health/behavioral, developmental,
and parenting difficulties, as well as frequency of
screening for mental health/behavioral, developmen-
tal, and parenting problems. Students from both partici-
pating and non-participating schools reported that they
screened sometimes to often for nearly all of these prob-
lems. For one item (i.e., how often do you screen for
stress and coping skills), the graduates from the non-
participating schools reported that they screened
more often for these skills (M = 3.1; SD = 1.04) than
did those from the participating schools (M = 2.74;
SD = 1.07; P .05). The only other item that was statis-
tically different between the graduates from participat-
ing and non-participating schools in 2004 was in how
much they believed that EBP improves patient out-
comes. In response to that item, graduates from partici-
pating schools had stronger beliefs that EBP improves
patient outcomes (M = 4.56; SD = .70) than did those
from non-participating schools (M = 4.34; SD = .72;
P .05). In addition, there were no statistically signifi-
cant differences in students’ perception of how well
their PNP program prepared them to assess and inter-
vene for mental health/behavioral problems, as well
as in how well their program prepared them in EBP
between participating and non-participating schools.
The majority of graduates from both participating
and non-participating schools reported that they did
not use screening tools to assess for mental health/be-
havioral problems. Overall, graduates from participat-
ing and non-participating schools in 2004 reported
that their programs only prepared them somewhat for
how to assess and manage mental health/emotional
problems in children. The areas in which the graduates
from both participating and non-participating schools
reported having the greatest needs were in easy-to-
use screening tools and interventions for mental
health/behavior problems that can be used in primary
care.
Students’ knowledge of screening and interventions
for mental health/behavior problems in 2004 and
2007 data were analyzed using t tests. Although mean
scores of each item were higher for students in the
2007 participating schools than in non-participating
schools, there were no statistically significant differ-
ences on these items between the two groups (Table 2).
Reported frequency of screening for mental health/
behavior problems of the 2004 and 2007 student data
was analyzed using t tests. In 2004, there were no statis-
tically significant differences in mean scores of screen-
ing frequency for depression, violence, sexual abuse,
and substance abuse between participating and non-
participating students. However, graduates from the
non-participating schools reported that they screened
more often for stress and coping in children than did
those from the participating schools. By 2007, although
students from the participating schools reported that
they screened more often than did graduates from
TABLE 3. Frequency of screening in clinical practice from the 2004 and 2007 student surveys
2004 2007
Variable
Participating
students (n = 139)
Mean SD
Non-participating
students (n = 51)
Mean SD
Participating
students (n = 116)
Mean SD
Non-participating
students (n = 54)
Mean SD
Depression 2.77 1.13 2.74 1.12 2.73 .98 2.67 .97
t = .133; df = 188; P = .894 t = .358; df = 168; P = .721
Anxiety 2.42 .99 2.66 1.07 2.42 .87 2.49 .96
t = –1.452; df = 188; P = .148 t = –.458; df = 168; P = .647
Violence 2.70 1.16 2.60 1.13 2.68 1.09 2.77 1.28
t = .553; df = 188; P = .581 t = –.479; df = 168; P = .633
Sexual abuse/Rape 2.56 1.17 2.58 1.21 2.55 1.11 2.54 1.17
t = –.139; df = 188; P = .889 t = .059; df = 168; P = .953
Sexual activity 3.40 1.20 3.31 .92 3.40 1.14 3.25 1.33
t = .497; df = 188; P = .620 t = .769; df = 168; P = .443
Substance abuse 3.20 1.19 3.19 1.11 3.20 1.10 3.17 1.37
t = .065; df = 188; P = .948 t = .152; df = 168; P = .880
Eating disorders 2.67 1.02 2.70 1.10 2.67 1.09 2.72 1.03
t = –.164; df = 188; P = .870 t = –.250; df = 168; P = .803
Stress and coping skills 2.74 1.07 3.09 1.04 2.85 1.02 2.81 1.14
t = .177; df = 188; P = .042* t = .262; df = 168; P = .793
Bullying 2.25 1.07 2.29 .92 2.34 1.02 2.36 1.15
t = –.237; df = 188; P = .813 t = –.096; df = 168; P = .923
ADHD 3.00 1.09 3.02 1.02 2.91 1.05 2.72 .97
t = –.111; df = 188; P = .911 t = 1.036; df = 168; P = .258
*P .05.

non-participating schools for depression, sexual abuse,
sexual activity, stress and coping skills, and attention
deficit hyperactivity disorder (ADHD), these differ-
ences were not statistically significant (Table 3).
Useofformalscreeningtoolsformentalhealth/behav-
ioral problems as reported by students in the 2004 and
2007 surveys was analyzed using v2
tests. In 2004, there
were no statistically significant differences in reports of
the use of formal screening tools between participating
and non-participating schools. By 2007, a larger propor-
tion of students in participating schools reported that
they used a substance abuse screening tool in their
clinical practice more than did non-participating school
students. Although students in participating schools
reportedthattheiruseofscreeningtoolsforanxiety,mar-
ital transitions, violence, sexual activity, eating disorder,
self-esteem, and ADHD was more than students in
non-participating schools, these differences were not
statistically different (Table 4).
In the follow-up assessment, items measuring how
well students’ PNP programs prepared them to assess
problems or intervene in clinical practice were ana-
lyzed using t tests. In 2004, graduates from participating
schools reported that they believe ‘‘EBP improves
patient outcomes’’ more than did those in the non-
participating graduates. In 2007, students in non-
participating schools reported that their PNP program
did a better job of preparing them for ‘‘interventions
regarding mental health/emotional problems,’’ ‘‘medi-
cations for mental health/behavioral problems,’’ ‘‘pro-
gram preparedness to practice as a PNP,’’ and
‘‘satisfaction with their current PNP program’’
TABLE 4. Use of formal screening tools in clinical practice from the 2004 and 2007 student surveys*
2004 2007
Variable
Participating
students
Non-participating
students
Participating
students
Non-participating
students
Depression
No 89 (65.4) 35 (68.6) 70 (63.1) 38 (71.7)
Yes 47 (34.6) 16 (31.4) 41 (36.9) 15 (28.3)
v2
= .169; df = 1; P = .731 v2
= 1.189; df = 1; P = .181
Anxiety
No 111 (81.6) 44 (86.3) 89 (79.5) 43 (81.1)
Yes 25 (18.4) 7 (13.7) 23 (20.5) 10 (18.9)
v2
= .567; df = 1; P = .520 v2
= .063; df = 1; P = .489
Violence
No 106 (77.9) 44 (86.3) 91 (82.7) 45 (84.9)
Yes 30 (22.1) 7 (13.7) 19 (17.3) 8 (15.1)
v2
= 1.623; df = 1; P = .224 v2
= .123; df = 1; P = .457
Sexual abuse/rape
No 108 (80.0) 43 (84.3) 94 (84.7) 45 (84.9)
Yes 27 (20.0) 8 (15.7) 17 (15.3) 8 (15.1)
v2
= .451; df = 1; P = .674 v2
= .001; df = 1; P = .971
Substance abuse
No 98 (72.6) 37 (72.5) 77 (69.4) 44 (83.0)
Yes 37 (27.4) 14 (27.5) 34 (30.6) 9 (17.0)
v2
= .000; df = 1; P = 1.00 v2
= 3.455; df = 1; P = .045†
Eating disorders
No 108 (80.0) 43 (84.3) 87 (79.1) 46 (88.5)
Yes 27 (20.0) 8 (15.7) 23 (20.9) 6 (11.5)
v2
= .451; df = 1; P = .674 v2
= 2.110; df = 1; P = .107
Stress and coping skills
No 117 (86.7) 43 (84.3) 94 (84.7) 47 (88.7)
Yes 18 (13.3) 8 (15.7) 17 (15.3) 6 (11.3)
v2
= .170; df = 1; P = .644 v2
= .475; df = 1; P = .333
Bullying
No 124 (91.9) 47 (92.2) 103 (93.6) 50 (94.3)
Yes 11 (8.1) 4 (7.8) 7 (6.4) 3 (5.7)
v2
= .005; df = 1; P = 1.000 v2
= .031; df = 1; P = .582
ADHD
No 62 (46.3) 29 (56.9) 50 (45.0) 29 (55.8)
Yes 72 (53.7) 22 (43.1) 61 (55.0) 23 (44.2)
v2
= 1.659; df = 1; P = .249 v2
= 1.631; df = 1; P = .134
*Screening tool items are coded 1 = not used and 2 = used.
†P .05.

compared with students in PNP programs in participat-
ing schools (Table 5).
Educational needs, such as more continuing educa-
tion (CE) on mental health/psychosocial morbidities
and more CE on EBP, were analyzed using t tests. In
2004, graduates in the participating group reported
that they need more effective brief intervention strate-
gies for mental health/behavioral problems than did
those in non-participating group (t = 2.851; df = 188;
P = .005). No statistically significant differences in
need items were found between the participating and
non-participating group in 2007 (Table 6).
We asked faculty how well prepared they believe
their graduates to be on a number of criteria. Faculty
from participating group schools in 2007 reported that
students were better prepared to assess and manage
mental/behavioral/psychosocial problems, develop-
mental problems, learning problems, and outcome
management problems, but the differences were not
statistically significant.
TABLE 5. Extent of PNP educational program preparation for clinical practice from the 2004 and 2007
student surveys
2004 2007
Variable
Participating
students (n = 139)
Mean SD
Non-participating
students (n = 51)
Mean SD
Participating
students (n = 116)
Mean SD
Non-participating
students (n = 54)
Mean SD
Intervention regarding
mental health/emotional
problems
2.87 .93 3.09 .94 2.99 .84 3.31 1.02
t = –1.435; df = 188; P = .153 t = –2.019; df = 168; P = .047*
Medications for mental
health/behavioral problems
2.68 .95 2.86 .91 2.65 .91 3.01 1.07
t = –1.174; df = 188; P = .242 t = –2.280; df = 168; P = .024*
Implementation
regarding EBP
4.13 1.00 4.09 .98 4.27 .87 4.29 .90
t = .244; df = 188; P = .807 t = –.129; df = 168; P = .898
Integration of EBP 4.26 .91 4.19 .93 4.32 .83 4.41 .85
t = .450; df = 188; P = .653 t = –.647; df = 168; P = .519
Belief that EBP improves
clinical care
4.56 .70 4.36 .68 4.50 .67 4.42 .81
t = 1.769; df = 188; P = .079 t = .661; df = 168; P = .509
Belief that EBP improves
patient outcomes
4.58 .67 4.34 .71 4.47 .63 4.42 .76
t = 2.127; df = 188; P = .035* t = .471; df = 168; P = .638
Program preparedness
to practice as a PNP
4.05 .82 4.08 .74 3.97 .77 4.22 .74
t = –.212; df = 188; P = .833 t = –2.001; df = 168; P = .047*
Satisfaction with
current PNP program
4.08 .98 4.14 .89 3.91 .97 4.42 .77
t = –.383; df = 188; P = .702 t = –3.395; df = 168; P = .001*
EBP, Evidence-based practice; PNP, pediatric nurse practitioner.
*P .05.
TABLE 6. Further needs of graduates from the 2004 and 2007 student surveys
2004 2007
Variable
Participating
students (n = 139)
Mean SD
Non-participating
students (n = 51)
Mean SD
Participating
students (n = 116)
Mean SD
Non-participating
students (n = 54)
Mean SD
More CE on mental health/psychosocial
morbidities
3.74 .92 3.60 .93 3.64 .74 3.55 .83
t = .913; df = 188; P = .362 t = .763; df = 168; P = .447
Easy to use screening tools 3.78 1.01 3.81 .95 3.59 .89 3.60 .93
t = –2.04; df = 188; P = .839 t = –.106; df = 168; P = .915
Educational support materials for families 3.66 1.04 3.54 1.11 3.45 .93 3.54 1.08
t = .715; df = 188; P = .476 t = –.506; df = 168; P = .614
Interactive Web site on developmental
and mental health/behavioral issues
4.07 .92 3.56 .98 3.56 .98 3.33 1.16
t = .572; df = 188; P = .568 t = 1.229; df = 168; P = .223
Effective brief intervention strategies
for mental health/behavior problems
4.07 .92 3.56 .98 3.83 .89 3.75 .84
t = 2.851; df = 188; P = .005* t = .545; df = 168; P = .586
More CE on evidence- based practice 3.15 1.16 3.08 1.09 3.56 .98 3.13 1.18
t = .378; df = 188; P = .706 t = –1.224; df = 168; P = .223
CE, Continuing education.
*P .05.

Ratings of faculty knowledge at baseline and follow-
up were compared within the participating schools. In
addition, faculty reports of their knowledge in the tar-
geted areas were compared for the participating and
non-participating schools in the 2007 faculty survey.
Faculty from the participating schools who completed
the follow-up survey reported significantly higher
knowledge than did faculty who completed the base-
line survey in the areas of EBP, screening for pediatric
mental health/behavioral problems, screening for de-
velopmental and learning disorders, screening tools
for mental health/behavioral problems, collaborative
interventions for mental health/behavioral problems,
psychopharmacology for mental health/behavioral
problems, and the healthy steps program. There were
no statistically significant differences in self-reported
knowledge between faculty from the participating
and non-participating schools from the 2007 faculty
survey (Table 7).
Faculty ratings of topics that need to be included in
PNP curriculums at baseline and follow-up were com-
pared within the participating schools. In addition, fac-
ulty ratings of topics that need to be included in PNP
curricula were compared from participating and non-
participating schools from the 2007 survey. Compared
with baseline responses, faculty from the participating
schools at follow-up reported a greater need to teach
concepts of the Healthy Steps program, screening for
mental health/behavior problems, screening tools for
developmental and learning disorders, assessment
and early intervention for conduct disorders, assess-
ment and early intervention for eating disorders, assess-
ment and early intervention for substance abuse,
assessment and early intervention for parent depres-
sion, assessment and early intervention for high paren-
tal anxiety, counseling for common parent concerns,
and behavior modification techniques. There were no
statistically significant differences in the faculty reports
of the need to teach these targeted areas between the
participating and non-participating schools from the
2007 faculty survey (see Table 8).
Within participating schools, faculty at baseline and
at follow-up from the participating schools were com-
pared regarding how much time faculty devote to pedi-
atric mental health topics and how well they believe
their graduate students are prepared for clinical prac-
tice. Faculty at follow-up from the participating schools
reported that more time was devoted to mental health/
behavioral problems than did faculty at baseline, and
they reported that their students were better prepared
to (a) engage in EBP, (b) provide parent counseling
for common behavior problems, (c) assess and manage
overweight and obesity, and (d) implement evidence-
based health promotion intervention programs. Faculty
from the participating schools versus faculty from non-
participating schools also reported that their students
were better prepared to assess and manage learning
disorders (see Table 9).
A total of 19 schools responded to the question
about the number of tools from the educational re-
source tool kit that they integrated into their PNP pro-
gram. Eleven of the 19 schools (57.9%) reported
TABLE 7. Ratings of faculty knowledge items by baseline/follow-up and the 2007 participating/non-
participating groups of faculty*
Variable
Baseline
Group (n = 20)
Mean SD
Follow-up
Group (n = 34)
Mean SD
Participating
Group (n = 38)
Mean SD
Non-participating
Group (n = 21)
Mean SD
EBP 66.8 19.5 90.4 8.8 87.68 15.9 91.0 5.7
t = –5.099; df = 52; P = .000† t = –.933; df = 57; P = .355
Screening for pediatric mental health/
behavioral problems
73.4 19.5 87.0 11.8 83.9 17.8 84.7 13.8
t = –3.223; df = 52; P = .002† t = –.182; df = 58; P = .856
Screening for developmental and
learning disorders
78.2 20.1 86.6 10.1 83.4 16.8 85.8 15.7
t = –2.059; df = 53; P = .044† t = –.531; df = 58; P = .598
Screening tools for mental health/
behavioral problems
68.8 18.0 84.3 12.9 81.7 17.9 79.9 17.6
t = –3.709; df = 53; P = .000† t = .376; df = 58; P = .708
Collaborative intervention for mental
66.5 21.9 78.8 15.2 76.6 19.3 78.0 15.4
t = –2.450; df = 53; P = .018† t = –.267; df = 58; P = .790
Psychopharmacology for mental
63.5 19.0 74.1 15.9 70.3 21.1 75.2 19.3
t = –2.217; df = 53; P = .031† t = –.886; df = 58; P = .379
The Healthy Steps program 51.7 27.5 82.1 20.5 76.2 25.4 60.5 36.0
t = –4.285; df = 52; P = .000† t = 1.938; df = 56; P = .058
Risk and protective factors for mental
health problems
77.1 174 88.4 10.7 85.1 18.7 75.6 24.1
t = –2.630; df = 52; P = .014† t = 1.668; df = 57; P = .101
Evidence-based health promotion
programs for use in primary care
settings
40.4 20.7 84.0 14.4 80.39 20.0 82.7 15.0
t = –4.923; df = 52; P = .000† t = –.451; df = 56; P = .654
Community resources in dealing with
mental health/behavioral problems
67.8 27.8 81.2 18.1 81.0 20.7 79.1 21.6
t = –2.172; df = 53; P = .034† t = –.239; df = 58; P = .812
EBP, Evidence-based practice.
*Knowledge items are coded 0 = ‘‘not at all’’ to 100 = ‘‘extremely.’’
†P .05.

integrating at least six of the 12 tools in the educational
resource kit into their curriculum. Among tools from
the educational tool kit, the KySS Guide was the
most frequently used (N = 15 schools, 78.9%), fol-
lowed by the Integrating Mental Health Screening
PowerPoint Lecture (N = 14 schools, 73.7%) and the
Mental Health Screening Lecture Video (N = 11;
57.9%) (Tables 10 and 11).
Students who completed the 2007 survey were
asked to make recommendations for strengthening de-
velopmental and mental/behavioral health in PNP pro-
grams and strengthening the PNP program that they
just completed. Content analysis was conducted to de-
termine key categories of the students’ responses and
was verified by two other team members. Five themes
were identified, including (a) higher quality experi-
ences in clinical sites, (b) strengthening course con-
tent, (c) incorporating screening tools, (d)
pharmacology management, and (e) better integration
of mental and physical health. Recommendations for
strengthening clinical experiences included (a) more
of a focus on the assessment, diagnosis, and treatment
of mental/behavioral problems, (b) greater opportuni-
ties to work with psychiatrists and other mental health
providers, and (c) the need to increase the numbers of
clinical hours focused on enhancing these skills. Stu-
dents also stated that more course content should fo-
cus on the assessment and diagnosis of common
mental health/behavioral problems. They also com-
mented that less content should be focused on theories
and, instead, that more emphasis should be placed on
practical approaches to assessment and management.
Students stated that they needed more information
on screening tools and how to use them as well as
what to do for positive screens. Some students com-
mented that better integration of coursework with clin-
ical experiences was needed, including the use of
screening tools as well as how and when to make re-
ferrals. Students also commented on the need for
more psychopharmacologic management in clinical
rotations.
Regarding strengthening the PNP program that the
students just completed, there was a significant differ-
ence between the participating and non-participating
groups of students (v2
= 15.897; df = 4; P = .003). Ap-
proximately 41% (n = 47) of the participating students
compared with 16.7% (n = 9) of non-participating stu-
dents responded that they needed a more integrated
approach between their academic course content and
experiences in their clinical rotations, including the
use of screening tools and practical pharmacologic
management in clinical sites.
Faculty who completed the 2007 survey also were
asked to comment on the topics that they believed
TABLE 8. Comparison of faculty baseline/follow-up ratings of topics that need to be taught in PNP
curricula from participating schools and 2007 participating and non-participating schools*
Variable
Baseline
Group (n = 20) Mean SD
Follow-up
Group (n = 35)
Mean SD
Participating
Group (n = 39)
Mean SD
Non-participating
Group (n = 20)
Mean SD
Concepts of the Healthy Steps
program
74.5 22.1 86.8 15.2 83.5 19.2 80.2 27.6
t = –2.447; df = 53; P = .018† t = .519; df = 57; P = .606
Screening for mental health/
behavior problems
94.6 7.0 99.2 2.4 96.2 14.7 92.5 14.0
t = –2.817; df = 53; P = .010† t = .927; df = 57; P = .358
Screening tools for developmental
and learning disorders
94.2 8.3 98.5 4.9 95.3 15.5 93.5 12.2
t = –2.118; df = 53; P = .044† t = .459; df = 57; P = .648
Motivational interviewing 79.0 24.3 89.8 15.0 86.6 19.6 82.5 16.8
t = –2.036; df = 53; P = .047† t = .771; df = 55; P = .444
Assessment and early intervention
for conduct disorders
80.5 24.2 94.7 7.7 91.0 16.4 89.5 12.8
t = –2.547; df = 53; P = .019† t = .367; df = 57; P = .715
for eating disorders
86.3 18.7 96.2 6.8 92.7 16.8 93.5 11.2
t = –2.226; df = 53; P = .037† t = –.169; df = 57; P = .867
for substance abuse
89.2 14.5 96.6 6.2 93.3 v 15.4 97.0 5.4
t = –2.159; df = 53; P = .041† t = 1.011; df = 57; P = .316
for parent depression
86.5 17.9 97.4 5.7 95.3 15.0 91.2 10.7
t = –2.665; df = 53; P = .014† t = 1.072; df = 57; P = .288
for high parental anxiety
87.3 15.2 96.1 8.3 94.1 15.9 90.2 11.7
t = –2.389; df = 53; P = .025† t = .973; df = 57; P = .335
Counseling for common parent
concerns
95.4 8.7 99.9 .3 97.6 14.4 96.2 6.6
t = –2.287; df = 53; P = .034† t = .401; df = 57; P = .690
Behavior modification techniques 83.8 17.9 92.8 10.0 90.4 16.4 87.0 13.3
t = –2.074; df = 53; P = .048† t = .818; df = 57; P = .417
PNP, Pediatric nurse practitioner.
†P .05.

should be added to their PNP curriculum. Key areas
identified by participating school faculty included
health behavior change, use of standardized situations,
counseling, psychopharmacology, early interventions,
and smoking cessation. Non-participating school fac-
ulty stated that more content was needed on mental
health disorders, psychopharmacology, motivational
interviewing, and counseling. Faculty from participat-
ing schools responded that the following skills needed
to be added to their curriculum: (a) counseling, (b) mo-
tivational interviewing, (c) cognitive-behavioral skills
building, (d) crisis management, (e) communication,
(f) EBP, and (g) screening for mental health problems.
Non-participating faculty also identified these as key
areas for skill building, in addition to assessment tools
and family assessment. When asked about content
that could be eliminated from their curricula, several
faculty from both groups of schools said ‘‘nothing,’’
but some identified that less content should be devoted
to rare diseases that are infrequently seen as well as care
of hospitalized children.
Faculty also were asked about current weaknesses of
their programs. Common responses from both partici-
pating and non-participating school faculty included
(a) library resources and distance learning technolo-
gies, (b) limitations in space, (c) insufficient opportuni-
ties for faculty practice, (d) competition for and
inadequate numbers of clinical placements, and (e) in-
sufficient content on mental health issues and stress
management.
Major weaknesses cited by faculty from both partici-
pating and non-participating schools related to mental
health/behavioral/developmental content in their pro-
grams included (a) lack of evidence-based interven-
tions to improve outcomes, (b) insufficient clinical
experiences and sites for mental/behavioral health ex-
periences, and (c) insufficient expertise and modeling
in these areas by clinical preceptors.
DISCUSSION
As indicated by the findings, the positive impact of the
project was most evident in enhancing faculty knowl-
edge in many of the targeted areas as well as in spurring
programs on to make important curricular changes in
their programs. Therefore, to create curricular change,
it is necessary to first focus on building faculty knowl-
edge and skills. At the first faculty workshop, one
TABLE 9. Comparison of faculty at baseline/follow-up from participating schools on time devoted to
pediatric mental health topics and preparation of students for clinical practice as well as
comparisons of faculty from participating and non-participating schools in the 2007 survey*
Variable
Baseline
Group (n = 20)
Mean SD
Follow-up
Group (n = 35)
Mean SD
Participating
Group (n = 35)
Mean SD
Non-participating
Group (n = 19)
Mean SD
Time devoted to mental health/
behavioral problems in your
curriculum
29.4 20.9 41.3 17.3 41.3 17.3 43.3 32.4
t = –2.277; df = 53; P = .027† t = –.2967; df = 52; P = .768
Engage in EBP 62.6 25.3 83.5 25.1 88.6 14.5 91.4 7.0
t = –2.957; df = 53; P = .005† t = –809; df = 51; P = .422
Provide parent counseling for
common behavior problems
71.5 27.7 87.0 18.5 89.5 10.9 88.6 12.9
t = –2.209; df = 53; P = .035† t = 1.004; df = 48; P = .321
Assess and manage learning
disorders
53.9 21.7 65.3 23.6 69.3 17.6 54.7 23.3
t = –1.777; df = 53; P = .081 t = 2.576; df = 51; P = .013*
Assess and manage overweight
and obesity
68.7 20.7 84.2 17.1 86.7 8.9 87.0 12.8
t = –3.000; df = 53; P = .004† t = .291; df = 52; P = .773
Implement evidence-based health
promotion intervention program
59.0 23.6 78.6 27.9 86.0 14.1 82.7 16.8
t = –2.644; df = 53; P = .011† t = –.089; df = 52; P = .929
EBP, Evidence-based practice.
†P .05.
TABLE 10. Number of tools from the
educational resource kit used by the 19
participating schools that responded to the
follow-up survey
No. of tools used
No. of schools
reporting use of tools %
1 3 15.8
2 1 5.3
4 1 5.3
5 3 15.8
6 3 15.8
7 2 10.5
8 3 15.8
9 1 5.3
11 1 5.3
12 1 5.3
Total 19 100.0

participant voiced a concern that was embraced by all:
‘‘We cannot teach what we do not know.’’ It quickly be-
came apparent that the first step in strengthening PNP
curricula would be to ensure a cadre of faculty who
were committed to learning what would be required
to teach students new knowledge and skills in the tar-
geted areas. Therefore, the educational workshops pro-
vided for the participating group faculty in year 1 of the
project were instrumental in strengthening their knowl-
edge of these topics so that they, in turn, could integrate
and teach the content in their programs. This is a critical
first step in the diffusion of knowledge to students. Al-
though not statistically significant, participating group
student findings on the follow-up survey demonstrated
a slight increase in their knowledge of screening and
interventionsaswellasastatisticallygreater useofasub-
stance screening tool in comparison with the non-par-
ticipating students, which may indicate an early
harbinger of the next step in the diffusion process.
Another key finding from this study is that partici-
pating in the project helped increase the awareness
and integration of behavioral and mental health con-
tent in the PNP curricula. On the follow-up survey,
faculty from the participating schools reported that
more time is now devoted to many of the key targeted
topics, that students are better prepared than previ-
ously, and they have a greater need to teach these
critical areas.
A great need still exists for programs to find ways to
incorporate more of this knowledge and skills into their
curriculums and clinical experiences, especially the use
of screening tools and early intervention practices. The
majority of students in this study were not incorporating
the use of readily available screening tools into their
well-child assessments, and frequency of screening by
graduates from both the participating and non-partici-
pating schools was relatively low. Students reported
that they screened the least for bullying, anxiety, sexual
abuse/rape, violence, eating disorders, and stress/cop-
ing. Furthermore, except for use of a screening tool for
substance abuse that was higher in participating than
non-participating school graduates, the majority of stu-
dents were still not incorporating the use of readily
available screening tools into their well-child assess-
ments. Open-ended comments from the students also
indicated that they needed more emphasis on screen-
ing in their programs, as well as the opportunity to prac-
tice these skills in their clinical practice sites.
Additionally, significantly more students from partici-
pating schools versus non-participating school re-
sponded that they needed a more integrated
approach between their academic course content and
experiences in their clinical rotations, including the
use of screening tools and practical pharmacologic
management in clinical sites. This finding indicates
that students from participating schools were probably
being exposed to more of this content in their curricula,
which helped them to recognize the gaps in the assess-
ment and management of these issues in their clinical
settings.
If screening is not routinely implemented by practi-
tioners, early identification and management of po-
tential and actual problems will not be realized.
Many students commented that their preceptors and
clinical sites are not incorporating screening tools
and that they are not being afforded opportunities
to focus on behavioral/mental health issues. If
preceptors are not modeling these behaviors and
practices do not incorporate them routinely, these
are major barriers in preparing graduates ready to
TABLE 11. Tools specifically integrated at the participating schools
Tools No. of schools reporting integration %
Introduction to the educational tool kit 9 47.4
Project overview PowerPoint slides 8 42.1
Integrating Healthy Steps article 10 52.6
Healthy Steps kit 10 52.6
Making a Case for EBP PowerPoint lecture 10 52.6
Integrating MH screening PowerPoint
lecture
14 73.7
MH screening lecture video 11 57.9
Connecting with children 8 42.1
Clinical interviews with children and
families with mental health/psychosocial
problems
7 36.8
Clinical log 5 26.3
Clinical skills checklist 5 26.3
KySS Guide to Child and Adolescent
Mental Health Screening, Early
Intervention and Health Promotion
15 78.9
EBP, Evidence-based practice; KySS, Keep your children/yourself Safe and Secure; MH, mental health.

enter practice with these skills to improve quality of
care to children and families.
Because of different processes for curriculum
change and approval in each of the colleges, it was im-
portant to allow individuation in the manner in which
the colleges strengthened their curricula in the tar-
geted areas. Some of the faculty from the participating
schools stated that curriculum changes were still on-
going; therefore, it is not surprising that there were
not many differences in outcomes yet between the
graduates from the participating and non-participating
schools. Surveying graduates again in another year or
two would be particularly helpful in assessing the im-
pact of diffusion of this content and skills in the curric-
ula. In addition, program integration of the tools in the
educational resource kit varied among the schools,
with only a little more than half of the colleges report-
ing that they integrated six of the 12 tools from the re-
source kit. Diffusion of all of the educational tools/
resources into the curricula by the participating
schools may have resulted in more potent outcomes
in the graduates.
Major changes have occurred in the United States in
the past 3 years, including an increased national em-
phasis on strategies to prevent and intervene early for
behavioral/mental health problems of children, as
seen in statements by the U.S. Surgeon General, the
Centers for Disease Control and Prevention, the Na-
tional Institute of Mental Health, the National Associa-
tion of Pediatric Nurse Practitioners, and the American
Academy of Pediatrics, as well as in efforts by national
organizations and foundations, such as the Common-
wealth Fund. It also is not uncommon to find national
magazines as well as local newspapers discussing the
growing numbers of children with behavioral, develop-
mental, and mental health concerns and the scarcity of
resources to address them. Students from both partici-
pating and non-participating schools have received
increased exposure to these problems as evidenced
by these national trends as well as the publication of
new PNP textbooks with added content in these areas
along with a major focus on mental health/behavioral
issues through NAPNAP’s KySS Program and National
Conference.
Limitations of this study were related to faculty turn-
over rates in the programs during the course of the
project as well as the variation in uptake of the tools
in the resource kit along with differences in curricu-
lum changes. In addition, student and faculty percep-
tions of their knowledge and skills were measured,
not their actual knowledge and skills. Future studies
should follow up with the students past graduation
into their practice settings to determine differences re-
lated to practice and patient outcomes. Finally, the stu-
dents completing the 2004 and 2007 surveys were
different groups of students, which did not allow for
assessment of change over time within a group; this is-
sue also may have affected the findings from this out-
comes evaluation.
SUMMARY AND CONCLUSIONS
This project can serve as a national model for other pro-
grams desiring to strengthen their curricula. As far as we
know, this is the first time in nurse practitioner educa-
tional history that a national concerted effort to
strengthen current nurse practitioner curricula was de-
signed, implemented, and followed by an outcomes
evaluation study with a consortium of colleges through-
out the United States. This study demonstrates a com-
mitment to the understanding that schools of nursing
must use the same principles of evidence that guide
quality health care in their curriculum design. Faculty
must continually evaluate curricula to ensure that
students are prepared to deliver primary health care
that is responsive to the changing morbidities and
needs of children and families in our society.
REFERENCES
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interventions for childhood disorders: Evidence base, contex-
tual factors, and future directions. Retrieved September 29,
2006, from http://www.apa.org/releases/Psychotropic
MedicationsReport.pdf
Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M.,
Murray, P., et al. (2005). Effectiveness of a quality improvement
intervention for adolescent depression in primary care clinics:
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Association, 293, 311-319.
Crowley, A., McGee, T. (2003). Integrating healthy steps into PNP
graduate education. Journal of Pediatric Health Care, 17, 232-
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Evans, D., Seligman, M. (2005). Introduction. In D. Evans, E. Foa.,
R. Gur., H. Hendin, C. O’Brien M. Seligman, et al. (Eds.),
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Greiner, A., Knebel, E. (2003). Health professions education: A
bridge to quality. Washington, DC: National Academic Press.
Hager, M. (2004). Pediatric education in the 21st century. New York:
Josiah Macy Jr. Foundation.
Hawkins-Walsh, E., Stone, S. (2004). A national survey of PNP
curricula: Preparing pediatric nurse practitioners to meet the
challenge in behavioral mental health. Pediatric Nursing, 30,
72-78.
Horwitz, S. M., Kelleher, K., Boyce, T., Jensen, P., Murphy, M., Per-
rin, E., et al. (2002). Barriers to health care research for children
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Janicke, D. M., Finney, J. W. (2003). Children’s primary health care
services: Social-cognitive factors related to utilization. Journal
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Melnyk, B. M., Brown, H., Jones, D., Kreipe, R., Novak, J. (2003).
Improving the mental/psychosocial health of U.S. children and
adolescents: outcomes and implementation strategies from
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Melnyk, B. M., Feinstein, N. F., Tuttle, J., Moldenhauer, Z., Here-
ndeen, P., Veenema, T. G., et al. (2002). Mental health worries,
communication, and needs of children, teens, and parents

during the year of the nation’s terrorist attack: findings from the
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Melnyk, B. M., Fineout-Overholt, E. (2005). Evidence-based prac-
tice in nursing healthcare. A guide to best practice. Philadel-
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and adolescent mental health screening, early intervention
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CALL FOR DEPARTMENTAL MANUSCRIPTS
HEALTH POLICY
The Journal is seeking manuscripts on current national and state child health policy and legislative activities. Advocacy is a key
role of Pediatric Nurse Practitioners in the care of children, and this column seeks to feature national and state policy issues that
impact on the health and well being of chiidren and families. Please submit inquiries to the Department Editor:
Karen G. Duderstadt, PhD, RN, CPNP
E-mail: Karen.duderstadt@nursing.ucsf.edu
Instructions for authors are available at www.jpedhc.org. The suggested word count for this department is 1500 words.
Manuscripts can be submitted to the Department Editor or online at http://ees.elsevier.com/jphc.
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