A Leadership Training Model

Infants & Young Children
Vol. 18, No, l , p p , 60-71
© 2005 Uppincott Williams & Wilkins, Inc.

A Leadership Training Model
to Enhance Private and Public
Service Partnerships for
Children With Special
Healthcare Needs
Diane L. Magyary, PhD, ARNP; Patricia Brandt, PhD, ARNP
Healthcare in this nation and the nature ofthe workforce are experiencing the most dramatic transformation in history. With healthcare reform, health professionals are increasingly being called
upon to be leaders in creating a wide variety of community partnerships to influence and document accessible, high-quality, cost-effective service systems. In particular, community partnerships between private and public sectors of society need to be coordinated to achieve optimal
health for children with special healthcare needs, and their families and communities. Healthy
People 2010 objectives encourage new partnership development between the private-public sectors of healthcare in collaboration with families and communities. The reformulation of healthcare and the workforce likewise calls for a revision of professional education to produce leaders who have the competency to create and engage in partnerships on behalf of children with
special healthcare needs. In this article, a nursing training grant's model of leadership is discussed that encompasses the full spectrum of private-public partnerships using the Maternal Child
Healthcare Service Pyramid model, with particular emphasis on the interface among 4 service levels: (1) direct healthcare services, (2) enabling/advocacy services, (3) population-based services,
and (4) infrastructure-building services. An additional leadership dimension, cultural competency,
is identified as an essential aspect of leaders who engage in partnership building with diverse communities. Finally, the training grant's formative and summative evaluation process is discussed, and
illustrated by presenting data that illustrate culturally competent leadership. Key words: children,
healthcare, leadership, nursing, training

HEALTHCARE REEORM AND THE
CALL FOR LEADERS
From the Departments of Psychosocial and
Community Health (Dr Magyary) and Family and
Child Nursing (Dr Brandt), University of
Washington, Seattle, Wash.

Healthcare in this nation and the nature of
the workforce are experiencing the most dramatic transformation in history (Pew Health
Professions Commission, 1995), With healthFundingfor this training grant was provided by theMatemai and Child Health Bureau, Public Health Service, care reform, professionals are increasingly beUS Department of Health and Human Services grant. ing called upon to engage in leadership acNumber 6 T80MC 00002-37. Appreciation is extended
to many colleagues who have participated in the train- tivities to improve the accessibility, quality,
ing grant over the years. Gratitude is extended tojody
and accountability of the healthcare system.
Okamura, the program coordinator who assisted in the Interdisciplinary leadership networks are inpreparation of this manuscript
creasingly being formed to shape the delivCorresponding author: Diane L Magyary, PhD, ARNP, ery of healthcare, with a particular emphasis
Department of Psychosocial and Community Health,
University of Washington, Box 357263, Seattle, WA on comprehensive and coordinated healthcare services delivered by interdisciplinary
98195 (e-mail: [email protected]).
60

A Leadership Training Model
teams of professionals (Committee on Quality
of Healthcare in America, 2001).
The reformulation of healthcare likewise
calls for a revision of professional education
to produce interdisciplinary leadership teams
to assure that the evolving healthcare system provides comprehensive and coordinated
services that are evidence-based, accessible,
equitable, of quality, cost-effective and provide culturally competent care to all populations including the underserved (Committee
on Quality of Healthcare in America, 2001;
Pew Health Professions Commission, 1995).
Leadership competencies, attitudes, and values have a fundamental impact on the healthcare system (O'Neil, 1993; Shugars, O'Neil, &
Bader, 1991). The Institute of Medicine Report Health Professions Education: A Bridge
to Quality (Committee on the Health Professions Education Summit, 2003) urges professional education to instill attitudes, values,
and competencies required to engage in interdisciplinary collaborative relationships with
diverse population of families, emphasizing
evidence-based comprehensive and coordinated care that is culturally respectful and
competent.
Formulation of nursing training
grant in response to the call for
leaders in healthcare
In response to the challenge of educating professional leaders for the 21st century, we developed a project focused on
the enhancement of clinical and leadership
competencies in the graduate preparation of
nurses who have a specialty with emphasis
on providing family-centered, culturally competent, and evidence-based comprehensive
healthcare to ethnically diverse and underserved populations of children with special
healthcare needs (CSHCN), within the context of their families and communities (Magyary, 2003; Magyary & Brandt, 1998). CSHCN
population was generally defined as "infants
and children who have or are at increased risk
for chronic physical, developmental, behavioral, or emotional conditions and who also
require health and related services of a type
or amount beyond that required by children"

61

(Office of State and Community Health, 1997,
p. 114). Educating leaders to advance healthcare for CSHCN is particularly important for
the following reasons:
• The prevalence of CSHCN has significantly increased (Children's Defense
Eund, 2001; Collins, 1997; Office of State
and Community Health, 1997; Simpson,
Bloom, Cohen, & Parsons, 1997).
• Families and communities are faced w^ith
enormous service and fiscal challenges to
enhance CSHCN optimal health and quality of life (Children's Defense Fund, 2001;
Ireys, Anderson, Shaffer, & Neff, 1997;
Newacheck & Taylor, 1992).
• CSHCN often do not receive services that
place emphasis on health promotion or
the emotional and behavioral aspects of
health (Community Tracking Study, 1997;
Ireys, Grason, & Guyer, 1996; Office of
Disease Prevention and Health Promotion
[ODPHP], 1997).
• Families have difficulty negotiating and
coordinating a patchwork of different service systems, including health, education,
and social/welfare (Blancquaert, ZvaguHs,
Gray-Donald, & Pless, 1992; Cartland &
Yudkowsky, 1992; Community Tracking
Study, 1997; Ireys et al., 1996).
• Primary care providers in managed care
plans are increasingly challenged to provide direct care and case management services to CSHCN, and yet these providers
often overlook early detection of CSHCN
and subsequently miss the opportunity
for early intervention. Moreover, managed care emphasis on cost containment
often deters the provision of communitybased comprehensive care by primary
care providers (Chrvala & Bulger, 1999;
Health Resources and Services Administration, 1999; ODPHP, 1997).

NEWLY DEFINED PRIVATE-PUBUC
SECTOR PARTNERSHIPS AT ALL LEVELS
OF HEALTHCARE SERVICES

The lack of accessible, community-based,
w^eU-coordinated,
and
comprehensive

62

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& YOUNG CHIUDREN/JANUARY-MARCH 2005

family-centered interdisciplinary healthcare
services for the CSHCN population highlights
the need for leaders to generate creative solutions across the entire spectrum of healthcare, inclusive of the private and public sectors of healthcare services. The formulation
of creative partnerships between the private
and public sectors of healthcare provides a
seamless interdisciplinary infrastructure to
assure that the day-to-day clinical practice
incorporates evidence-based "best practices"
for CSHCN populations, and their families and
communities. Newly defined private-public
sector partnerships will benefit CSHCN
populations through enhancement of optimal
health and quality of life, and also benefit private and public healthcare systems through
cost sharing and containment. Prominent
professional and governmental reports are
urging leaders to advance private-public
sector healthcare partnerships. The 1997
Improving Health in the Community report
(IOM) emphasized the need for personal
direct healthcare services and public health
activities to be coordinated and directed
toward improving the health of the entire
community within a socially and politically
responsible context (Durch, Bailey, & Soto,
1997). Healthy People 2010 action plan takes
into consideration that new relationships will
be defined between public health departments and healthcare delivery organizations
(ODPHP, 1997).
Conceptualization of leadership across
the private-public spectrum of
healthcare on behalf of CSHCN
For the purposes of our project, leadership was conceptualized to encompass the
fuU spectrum of leadership competencies required to generate, disseminate and implement evidence-based best practices at the individual level as well as at the aggregated
community health level, and thus ultimately
advance partnerships between private and
public sectors of healthcare. The Maternal
Child Health Bureau's Pyramid Health Care
Service Model provides a conceptual framework for defining the full spectrum of leadership competencies applicable to the private

and public sectors of healthcare. The 4 healthcare service levels, namely, direct healthcare services, advocacy (enabling) services,
population-based services, and infrastructurebuilding services (Office of State and Community Health, 1997), are interrelated and coordinated to advance the health of the entire
community (Fig 1).
Each healthcare service level and the interface among the service levels are essential to
advance community-based, comprehensive,
coordinated, family-centered healthcare for
CSHCN, and their families and communities.
The definitions of leadership competencies
associated with each of the 4 healthcare service levels w^ere revised and expanded upon
to identify specific clinical and leadership activities on behalf of the CSHCN population
(Brandt & Magyary, 1999). It is rare to find a
graduate healthcare program that emphasizes
the interface across all 4 healthcare service
levels. For example in nursing. Nurse Practitioner graduate programs typically emphasize direct healthcare and advocacy services;
in contrast. Community Health Nursing graduate programs typically emphasize aggregate
focused population-based and infrastructurebuilding services. The cross-fertilization of
strengths from each program enhances leadership development across the entire healthcare service spectrum that are interrelated
through private and public healthcare partnerships. The nursing training grant offered
students a unique opportunity to engage in
cross-fertilization-type activities. Nurse Practitioner students with Community Healthcare
students jointly engaged in training grant
activities designed to cultivate appreciation
for the entire spectrum of the 4 healthcare
service levels that are interrelated through
private-public partnerships.
Culturally competent leadership
An emerging challenge for the 21st century is the formulation of private and public
partnerships in delivering culturally relevant
and sensitive healthcare services to an increasingly diverse population. By the year 2010,
a dramatic increase w^ill occur in the numbers of racial and ethnic minority populations.

A Leadership Training Model

63

DIRECT
HEALTHCARE
SERVICES
Examples:
Interdisciptinary
Basic Heatth Services,
and Health Services for CSHCN
ADVOCACY SERVICES

Examples:
Transportation, Translation, Outreach,
Respite Care, Heatth Education, Famity
Support Services, Purchase of Health Insurance,
Case Management, Coordination with Medicaid,
WIC, and Education
POPULATION-BASED SERVICES

Examples:
Newborn Screening, Lead Screening, Immunization,
Sudden Infant Death Syndrome Counseling, Orat Heatth,
Injury Prevention, Nutrition and Outreach/Public Education
INFRASTRUCTURE BUILDING SERVICES

Examples:
Needs Assessment, Evaluation, Planning, Policy tDevetopment,
Coordination, Quatity Assurance, Standards Development, Monitoring,
Training, Apptied Research, Systems of Care, and Information Systems

Figure 1. MCHB pyramid model encompasses 4 interrelated healthcare service levels. From "Background
and framework of Title v Block Grant Guidatice, the HSRA Performance Measurement Systems." by Office
of State and Community Health, 1997.

estimating to comprise 40% of the US population. And yet, typically in the United States,
professionals are not racially or culturally representative of the people they serve, or have
developed knowledge and experience using
culturally competent approaches (Committee
on Ways and Means, 1992; Smedley, Stith,
& Nelson, 2003). Racial and ethnic minority
populations including CSHCN typically have
more negative developmental and health outcomes in comparison to Caucasian populations (Smedley et al., 2003). This disparity in
health outcomes is due to a variety of reasons
such as lack of access to quality and culturally
sensitive healthcare (Committee on Quality of
Healthcare in America, 2001; Cross, Bazron,
Dennis, & Issacs, 1989; Smedley et al., 2003).
In acknowledgment of the importance of
culturally competent care, cultural competency was explicitly extracted as a separate
leadership dimension to be emphasized, de-

veloped, and evaluated during the student's
course of study. Cultural competency is conceptualized as a necessary leadership quality
for the successful implementation ofthe 4 levels of healthcare services. Culturally competent care is defined as the provision of services
to families and communities that honor different beliefs, values, and interpersonal styles
and behaviors within the collaborative process of partnership building and the incorporation of multicultural professionals, community leaders, and lay representatives in the
policy development, administration, and the
provisions of services within the collaborative process of partnership building (Office
of State and Community Health, 1997). Inherent in this definition of culturally competent
care is the core concept of collaborative partnership building among families, communities, and professionals at each of the 4 healthcare service levels. Collaborative partnership

64

INFANTS

& YOUNG CHILDREN/JANUARY-MARCH 2005

building is more likely to be successful and effective if completed in the context of culturally sensitive interactions. An evolving body
of research substantiates that better health
outcomes occur if the family participates in
the decision-making process with culturally
sensitive professionals (Association of American Medical Colleges, 1999; Committee on
Quality of Healthcare in America, 2001). Families and communities included in healthcare planning and policy development enhance the cultural sensitivity and quality of
healthcare services (Barger, 1997; Bournes &
DasGupta, 1997).
The past 2 decades have -witnessed a
strong evolving emphasis on collaboration
among families, communities, and professionals. Several significant laws and policies
emphasize collaborative partnership building
between families with CSHCN and systems of
healthcare as well as public education (Healy
et al., 1989; Shelton & Stepanetk, 1994). The
Washington State Health Care Policy Board
(1997) endorsed "partnership networks"
among families, communities, health providers, and health plans as the primary way to
promote access to high-quality, affordable.

culturally competent services for CSHCN.
The National Institute of Nursing Research
Expert Panel on Community-Based Healthcare (1995) emphasized the critical nature
of community partnerships to advance
healthcare as highlighted by Barger (1997),
stating, "community-based care is founded
on partnerships between consumers and
providers of care and through these partnerships, services are developed and promoted
that are both sensitive and relevant to the
cultures and mores of the individuals, families, populations and communities to which
care is directed" (p. ll).The complexity of
developing successful and effective privatepublic healthcare collaborative partnerships
with families and communities across the
4 levels of healthcare requires professional
leaders who are culturally competent and
sensitive. The training grant's culturally competent leadership model encompasses the
dimensions of (a) multicultural competency,
(&) complexity of human development and
diversity, and (c) social-political responsibility
and activism (Magyary and Brandt, 1999).
Figure 2 illustrates the training grant's
culturally competent leadership model.

MULTICULTURAL COMPETENCY

Congruency
Attitudes/Beliefs/Values/Knowledge/Skills

COLLABORATIVE
PROCESS
OR
PARTNERSHIP BUILDING
WITH
FAMILIES,
COMMUNITIES, AND PROFESSIONALS

COMPLEXITY
HUMAN DEVELOPMENT AND DIVERSITY

Person-centered Knowledge
Culture-centered Knowledge

SOCIAL -POLITICAL
RESPONSIBILITY AND ACTIVISM

Active Stance Against Oppression
Active Stance Against Disparity
in Healthcare/Health Status
Validation of Strengths and Assets

Figure 2. Culturally competent leadership in the context of collaborative partnership building.

A Leadership Training Model
Multicultural competency
Multicultural competency is a way of thinking and interacting that requires ongoing
learning. A "culturally competent professional" has been defined in many ways; however, a consistent definitional theme highlights the notion of congrueney in one's
attitudes, beliefs, knowledge, and skills in actively demonstrating culturally sensitive care.
Sue, Arredondao, and McDavis (1992) identified 3 congruency dimensions that characterize a culturally competent professional. These
dimensions were adapted to apply to both individual and systems of care.
• Individual and institutional aw^areness of
one's ow^n assumptions about human behavior, values, biases, preconceived notions, personal limitations, and so forth
(Sue et al., 1992, p. 75).
• Individual and institutional understanding of the worldview of culturally different clients/populations without negative
judgment (Sue et al., 1992, p. 75).
• Individual and institutional development
and delivery of appropriate, relevant,
and sensitive interventions/programs and
policies in working with culturally different clients/populations (Sue et al., 1992,
p. 75).
Complexity of human development
and diversity
ImpUcit in multicultural competency is the
recognition that human beings are complex
and multidimensional. Multiculturally sensitive and competent healthcare providers are
required to consider the interplay between individuals and collective units. One's socially
constructed identity is influenced by one's
age, socioeconomic class, race/ethnicity, gender, sexual orientation, religion, health condition, disability, etc. For example, a child's
definition of self and the meaning ascribed
to life experiences are socially constructed
through various ongoing bidirectional interactions with significant collective units such
as faniily, school, community, and healthcare
system. The child's inherent neurobiological

65

propensities such as temperament and cognitive and emotional disabilities interact with
environmental socialization processes within
the family and the broader community. This
complex developmental process has been referred to in the literature as a transactional
ecological developmental perspective.
Given the complexity of developmental
processes, consideration of both "culturecentered collective knowledge" and "personcentered individual knowledge" enhance
appreciation for the complexity of human
diversity. Sasao and Sue (1993) conceptualize
cultural complexity at 2 levels, the individual level and the larger collective level.
Taking into consideration these 2 levels of
complexity, cultural competency entails the
interface between 2 types of knowledge.
Culture-centered collective knowledge is
understanding how a child or a family, or
both, perceives itself as being similar to its
identified social-cultural unit. This type of
knowledge requires an understanding about
commonalties that characterize social-cultural
groups. Person-centered individual knowledge is understanding how a child or a family,
or both, perceives itself as being different
from its identified social-cultural unit. This
type of knowledge requires an understanding
about individual variations often referred to
as "w^ithin-group differences." Sometimes,
individuals may perceive themselves as being
positioned outside the group norms, thus
being a minority who may be marginalized
even within their own cultural group. In
addition, generational differences and levels
of acculturation often exist within socialcultural groups or even within a faniily that
holds multiple perspectives and values.
Two competency skills that incorporate
the notion of person-centered knowledge
and culture-centered knowledge is "scientific
mindedness" and "dynamic sizing," as proposed by Sue (1998). Scientific mindedness
requires professionals to explore and check
out a family's social-cultural identity rather
than making premature conclusions. Professionals need to invite family members to
share their various perspectives and values.

66

INFANTS

& YOUNG CHILDREN/JANXJARY-MARCH 2005

Dynamic sizing requires professionals to understand when to generalize behaviors that
reflect a collective sense of identity versus
knowing when to individualize behaviors that
reflect an individualized sense of identity that
is different from one's social-cultural group.
The competency skills of scientific mindedness and dynamic sizing become critical when
professionals are trying to understand how
CSHCN and their families view^ their socialcultural identity as well as their individualized
sense of self and of family.
Social-political responsibility
and activism
Multicultural competency that embraces
the complexity of human diversity protects
against stereotypical thinking, prejudices, and
discriminatory behaviors directed toward different collective social-cultural groups and individuals within those groups. As professionals develop collaborative partnerships with
families and communities, they cultivate an
understanding of socioeconomic and political influences on health disparity. Over time,
this understanding is translated to the development and promotion of programs, policies, and legislation that validates an orientation to strengthen assets and protective
factors within families and communities. Professional, community, and family partnerships
created to advocate on behalf of CSHCN have
advanced quality, comprehensive, accessible,
and culturally competent healthcare over the
years.
EVALUATION OF TRAINING GRANT

An essential component of the training
grant was the implementation of an evaluation model to document, evaluate, and
enhance the grant's achievement of performance outcomes—in particular, the education and socialization of culttarally competent
nursing leaders who advance healthcare for
CSHCN and their families. Both quantitative
and qualitative data collection methods were
used to collect formative evaluative data during the graduate program and summative eval-

uative data after the graduate program of studies. For the purpose of this article, examples
of formative and summative evaluation will be
presented to illustrate the translation of the
leadership and the culturally competent conceptual model to actual educational experiences and outcomes.
Formative evaluation during
graduate studies
Leadership portfolio
Each student documents their evolving
mastery of leadership and cultural competencies by completing on a quarterly basis the
training grant's Web-based Leadership Portfolio (Brandt & Magyary, 1999). The Leadership Portfolio template is based on the
training grant's conceptual pyramid model
of leadership service levels (infrastructurebuilding services, population-based services,
advocacy/enabling services, and direct healthcare services), with the addition of cultural
competencies. Each student describes their
leadership activity for the quarter, articulates
how the leadership activity interfaces with
the specific leadership and cultural competencies, and plan their ongoing developmental leadership goals for the future. Particular
emphasis is placed on the development of
leadership competencies that advance healthcare services for CSHCN, and their families
and communities. Leadership competencies
are advanced through nursing and interdisciplinary coursework, scholarly projects,
fieldwork, clinical leadership practicums,
community-based partnership-building activities, and clinical scholarly projects, theses,
and dissertations.
Cotntnunity-catnpus partnerships
As students think about their leadership
goals and evaluate their advancement in leadership competencies through completion of
the Leadership Portfolio, innovative interdisciplinary collaboration with families and
communities is also emphasized. Eaculty encourage and mentor student participation
in interdisciplinary types of higher education and community partnership projects as

A Leadership Training Model
fostered by the "Community Campus Partnerships for Health for Creating Healthier Communities," an interdisciplinary organization
that (a) strengthens partnerships between
health professionals, educational institutions,
and communities, including service agencies
to address unmet health needs and improve
the health of communities; (fo) instills an ethic
of community service and social responsibility in health professions schools, students,
and faculty; and (c) equips the next generation of health professionals with communityoriented leadership competency (Seifer &
Conners, 1997). One of the training grant's
process goals measured on a quarterly basis
was the involvement of faculty and students
in campus-community partnership-building
activities.
An example of one of the training grant's
campus-community partnership projects involved the collective effort by faculty, students, community-based clinicians, and lay
representatives jointly engaged in a process
to develop, test, and refine a Decision Tree
and Clinical Path for the Assessment and Treatment of Children with self-regulatory disorders such as Attention Deficit and Hyperactivity Disorder (Magyary & Brandt, 2002). The
collaborative effort Ulustrates how the 4 leadership levels of the MCH Pyramid Model are
encompassed within the ADHD collaborative
project.
The first level of the MCH Pyramid Model,
infrastructure building, involved a clinical research process that began with a community
needs assessment asking pediatric-oriented
professionals to identify gaps in their clinical
expertise. Professionals from a wide variety
of healthcare systems (primary care clinics,
mental health clinics, school health clinics,
and public health departments) expressed
concerns about their expertise in behavioral
assessments, with special notation placed on
the assessment, diagnosis, and treatment of
young children challenged with ADHD. Given
these concerns, a clinical research project was
initiated to develop the Decision Tree and
Clinical Path for the Assessment and Treatment of Children With Attention Deficit and

67

Hyperactivity Disorder (Magyary & Brandt,
2002; Magyary, Brandt, & Kovalesky, 1996).
The second MCH Pyramid Model leadership level, population-based services, involved explaining to administrators the costbenefits of systematically incorporating the
ADHD Decision Tree and Clinical Paths in the
healthcare program for high-risk clinical population groups. The third MCH Pyramid Model
leadership level, advocacy/enabling services,
involved demonstrating how to use the ADHD
Decision Tree and Clinical Path educational
materials for case management, service coordination, and family empowerment services.
Special emphasis is placed on cultural sensitivity by assuring that the family's personal
health and cultural beliefs, knowledge, attitudes, and response patterns are understood
and respected. Finally, the fourth MCH Pyramid Model leadership level, direct healthcare
services, entailed assisting professionals to
systematically incorporate the ADHD Decision Tree and Clinical Path in their daily clinical practice in collaboration with families.
Dissemination of the ADHD Manual has
occurred through in-services, workshops,
courses, and distance-learning modalities
involving more than 1000 professionals
representing a variety of disciplines. Ongoing
feedback from professionals and families
identify the urgent need to detect and treat
self-regulatory disorders, including ADHD
expressed earlier in life. As Arons, Katz-Leavy,
Wittig, and Holden (2002) state, "Whereas
great progress has been made in diagnosing
and treating children with ADHD, scientists
and physicians are still struggling to understand the disorder among preschoolers"
(p. S58). The high prevalence of disruptive
behaviors in very young children, aged 1-4
years, has generated theory development and
empirical investigation in the early expression
of self-regulatory developmental disorders
that involve mood/affect, motor-sensory,
attentional, physiologic, and behavioral
systems (Thomas & Clark, 1998). The Zero
to Three Diagnostic Classification System for
Mental Health and Developmental Disorders
of Infancy and Early Childhood (National

68

INFANTS

& YOUNG CHILDREN/JANUARY-MARCH 2005

Center for Clinical Infant Programs, 1994)
offers a useful way to conceptualize and
operationally define self-regulatory disorders
within the dyadic parent-child relationship.
Currently, an interdisciplinary team of faculty,
students, and community-based professionals
with families are engaged in developing a
clinical research protocol based on the Zero
to Three Diagnostic Classification System
that will be used in primary care settings
for the early detection and treatment of
self-regulatory disorders expressed by infants,
toddlers, and preschoolers.

SUMMATIVE EVALUATION
POSTGRADUATION

For the purposes of this article, examples
of postgraduate leadership activities will be
highlighted illustrating how graduates are performing culturally competent leadership activities across the levels of the MCHB Pyramid Model of Care on behalf of children
and adolescents with special healthcare needs
and their families. Data were collected on 39
master's-level nursing graduates who had enrolled during the 2-year curricular grant period from Fall 1998 to Winter 2003 (Magyary,
2003).
Employment
The Graduate Questionnaire consisted of
10 close-ended questions designed to obtain
employment information with respect to position, responsibilities, location, and populations served. Master's prepared graduates
competitively engage in the hiring process because of their clinical competencies to combine primary and specialty care for CSHCN
and because of their leadership competency
to conceptualize healthcare across the entire
private-pubUc spectrum ofthe 4 service levels
as depicted by the MCHB pyramid model. The
consistent theme demonstrated by the majority of the master's prepared graduates is that
they have taken the initiative to create new
nursing roles that integrate clinical expertise

with leadership functions. The newly created nursing roles are implemented within the
context of interdisciplinary collaborative partnerships with families and communities to
advance healthcare for children/adolescents
with special healthcare needs, and their families and communities.
The majority of master's prepared graduates have found employment as certified
nurse practitioners or clinical nurse specialists w^ho integrate advance practice with leadership responsibilities. The nurse practitioner
students have obtained advanced practice
certification at the national level as pediatric
nurse practitioner or psychiatric nurse practitioners. AU of the employed graduates are
providing services and leadership activities
on behalf of chUdren/adolescents with special healthcare needs that include physical,
developmental, neurobiological, and/or
psychological conditions often coupled with
environmental risk/protective factors. Eightyseven percent of the employed graduates
provide services to populations who are
"medically underserved"as defined by a shortage of health professionals and/or healthcare
services directed to both private and public
agencies with families who are underinsured,
homeless, residents of public housing, and/or
recipients of welfare. These populations were
also characterized by a large percentage of
ethnic minorities. Graduates tended to be
employed by inpatient hospitals, outpatient hospital clinics, community clinics,
government-related health facilities, public
health departments, home care facilities,
and child developmental centers. The geographic location of employment included
rural, inner-city urban, urban, and suburban
areas.
The 4 MCH core leadership functions were
incorporated into graduates' job responsibilities with a designated average percentage
of time devoted to infrastructure building
(21%), population-based services (17%), enabling/advocacy services (14%), and direct
healthcare services (48%). Culturally competency at each of the 4 levels of services was

A Leadersijip Training Model
evaluated through self-analysis as well as system and policy analysis.
Leadership examples
The Graduate Profile form consists of 20
open-ended questions asking graduates to describe specific leadership activities and how
their leadership activities affect healthcare
for CSHCN, and their families and communities. Graduates described participation in
leadership activities that encompass the 4 service levels of the MCHB Pyramid Model, often requiring an interdisciplinary collaborative effort in partnerships with families and
communities. The following is a compilation of those leadership activities (Magyary,
2003):
• 33 clinical studies and demonstration
projects
• 12 community-based assessment projects
• 52 healthcare service program evaluation
projects or quality assurance projects
• 19 leadership roles in care coordination/
case management activities
• 26 interdisciplinary and/or interagency
partnership-building programs
• 18 advocacy service activities
• 20 standards of care activities
• 45 membership or leadership roles in national professional organizations
• 13 participant roles on advisory board/
council
• 8 publications in peer-reviewed journals
• 3 study guides for Reagents CoUege
exams
• 9 presentations at regional conferences
• 35 continuing education/in-service guest
lecture presentations and university-level
lectures
• 19 family health educational materials/
products developed and disseminated
The following are selected descriptive
examples of graduate leadership activities
and how these leadership activities have affected healthcare on behalf of CSHCN, and
their families and communities (Magyary,
2003).
• Clinical demonstration project resulted in
the development of a statewide, funded

69

pilot interdisciplinary service program
for substance-abusing mothers and their
infants.
Quality assurance activities resulted in
the development of interdisciplinaryteam pain control protocols and standards including young children; modification of the pain management services to
be more responsive, available, and standardized; the development of pain control educational materials and the provision of community outreach educational
and in-service programs.
Community needs assessment resulted
in an interdisciplinary transition service whereby NICU discharge service
is coordinated with primary care and
community-based early intervention services as one seamless program.
Community needs assessment and program development activities resulted in
the adaptation of a tuberculosis teaching
kit to enhance therapeutic adherence and
decrease the potential spread of tuberculosis among east African refugees' families
who have a child newly diagnosed with
tuberculosis.
Community partnership-building activities resulted in interdisciplinary
consultant service between a neurodevelopment center and a state-supported
day care that serves infants and young
CSHCN.
Program planning activities in collaboration with African American families resulted in the development and evaluation of comprehensive inpatient and outpatient services for children with sickle
cell and their families, including community and school outreach educational
programs and the annual summer camp
program supported by state funds for
genetics.
Program development activities in collaboration with the community expanded
the breadth of WIC services, which increased breast-feeding, vaccinations, and
primary care among Native American infants and children.

70

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& YOUNG CHILDREN/JANUARY-MARCH 2005

• Initiation of a case management program
resulted in timely coordinated access
to comprehensive primary and specialty outpatient services for infants and
CSHCN.
• Chart review on breast-feeding rates resulted in the collaborative development
of a lactation support program with
Hispanic mothers in a primary care site.
• Advocacy building with mental healthcare agencies created avenues for timely
referrals and access to mental health services, including young children.
SUMMARY

The MCH pyramid model on healthcare service levels coupled with a cultural competency conceptual framework proved to be

useful in training nursing leaders with an emphasis on leadership activities that interface
the private and public sector within the evolving healthcare system. Culturally competent
leadership development through collaborative campus-community partnership building
was emphasized across the entire healthcare
service spectrum (direct healthcare, advocacy, population-based programs, and infrastructure building). The interdisciplinary educational process enriched the nursing training
grant's emphasis on famUy-centered comprehensive and well-coordinated healthcare services involving teams of different disciplines
and ethnically diverse teams of healthcare
providers. Ultimately, interdisciplinary collaboration w^Ul result in a well-coordinated and
comprehensive delivery of healthcare that
better serves CSHCN, and their families and
communities.

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