By Giddens, Jean Brady, Debra; Brown, Pauline; Wright, Mary; Smith, Debra; Harris, Judith
ABSTRACT The need for curriculum reform, a common theme in the nursing and health sciences literature for a number of years, is becoming urgent. This article describes an innovative undergraduate nursing curriculum. Central to the curriculum revision were the adoption of a conceptual approach, the institution of clinical experiences driven by conceptually based learning, and a focus on experiences across population groups and practice settings. An innovative, web-based community was developed as a platform for the curriculum.
Key Words Nursing Education – Concept-based Curriculum – Nursing Curriculum – New Pedagogies – Clinical Teaching
OVER THE PAST DECADE, there has been growing evidence of the need for change in health professions education. Multiple issues concerning educational preparation and entry into practice are cited by the Institute of Medicine (I), giving rise to a call for major educational reform that is echoed in the nursing literature. Tie Essentials of Baccalaureate Education for Professional Nursing Practice, which details core standards for baccalaureate education, has been influential in curriculum development since 1998, but its authors have asked if it is even possible to “prepare beginning- level professional nurses for the future in a four-year time frame” (2, p. 19). * Tanner described the expectations set forth in The Essentials as a “blueprint for the 21-year curriculum” (3, p. 383), but she was unable to identify any of the core knowledge and competencies outlined in The Essentials that could be eliminated. MORE RECENTLY, THE NATIONAL LEAGUE FOR NURSING HAS CALLED FOR DRAMATIC REFORM, WITH A CHALLENGE TO RETHINK THE EMPHASIS ON CONTENT AND OUTDATED TEACHING PRACTICES (40). THE NLN SUGGESTS THAT A COMPLETE PARADIGM SHIFT IN NURSING EDUCATION is NEEDED. * With these issues in mind, our institution developed and implemented a new undergraduate curriculum to foster a conceptual understanding of nursing practice. The new curriculum has four unique features that are consistent with suggestions found in the nursing education literature:
* Three undergraduate options are merged under one program of study.
* A conceptual approach has been adopted.
* New approaches to clinical education have been instituted.
* An innovative, web-based teaching platform has been created.
Merging Undergraduate Tracks Like many other nursing programs, our program has several options available to obtain a baccalaureate degree in nursing: a four-year track for traditional students; a track for students with a previous bachelor’s degree in a field other than nursing (second-degree track); and an online RN-BSN track. In reviewing the curricular needs of these three options, faculty identified a need to minimize duplication of content between courses in the various tracks.
Duplication of content creates an obvious drain on already stretched faculty resources, and there was consensus that all students need the same nursing curricular preparation for degree and licensure. While consolidation of tracks has been identified as a short-term strategy to expand the capacity of current faculty (5), there remained the challenge of how to provide the same curriculum to the traditional and second-degree tracks while still providing a mechanism to obtain the degree in the shortest time possible.
It was determined that the primary curricular differences between traditional and second-degree tracks would be the necessary prerequisite courses. In addition, whenever possible, courses would be shared by all three tracks; thus, only four courses unique to the RN-BSN track were developed. Because of these changes, the new curriculum successfully addresses the curricular and timeliness needs of the three undergraduate tracks while reducing course redundancy and expanding faculty capacity.
Conceptual Approach One of the many challenges of health professions education is the management of curricular content. Because of an ongoing emphasis on content, most nursing programs have fallen victim to what has been called content saturation. Giddens and Brady (6) attribute this phenomenon to multiple variables, including the information age, changes in health care delivery, and the ongoing teacher-centered approach to teaching. The nursing literature provides ample evidence that many faculty, and students, are overwhelmed with content (7-9).
Over the past decade, concept-based curricula have been largely adopted in primary, secondary, and postsecondary education (10); similarly, a conceptual approach has been advocated as a framework for nursing education, practice, and research (11). Such an approach offers three major advantages for nursing: content is deemphasized, thus leading to content management; conceptual learning fosters critical thinking; and there is a deemphasis of the artificial boundaries that result from population-based or settingbased instruction.
Concept-based courses provide the foundation and structure for delivery of nursing content and serve as cornerstones for conceptual learning in the new curriculum. Faculty agreed to move away from the traditional specialty model (i.e., adult health, maternalchild health, mental health) to concept-based courses, in which concepts are presented representing a wide range of applications. The teaching strategies used also foster active learning and critical thinking skills.
Two general groups – health and illness concepts and professional nursing concepts – were identified and defined by curriculum committee members. (see Table on the following page.) Exemplars based on state, national, and global health incidence and prevalence statistics for population groups, throughout the lifespan or of importance within practice, were selected to represent the concepts.
HEALTH AND ILLNESS COURSES Health and illness concepts form the basis for a series of three courses known as the Health and Illness Courses. The concepts and content presented within these courses represent the core knowledge of patient-centered nursing care. All concepts are presented on three continua: age, health, and environment.
Because they cover individuals of all age groups, concepts are presented across the lifespan. No attempt is made to feature every age group with every concept, but all age groups are well represented. The health continuum incorporates wellness, health promotion, acute illness, and chronic illness as they apply to the concept. Finally, these concepts represent nursing care in both inpatient and community settings, thus emphasizing nursing care in a variety of environmental contexts. As an example, the concept of infection is represented in age, health continuum, and environment through otitis media, influenza, and wound infections.
PROFESSIONAL NURSING COURSES Professional nursing concepts provide the foundation for a series of courses known as Nursing Concept Courses. These courses focus on professional attributes, core roles, and the context in which nurses practice. Concepts are presented at the individual nurse, patient, team, unit, organization, or system level. Exemplars selected to represent the concepts are based on professional significance at the national or international level.
Some nursing concepts are featured in multiple courses with exemplars of increasing complexity. For the concept health care system, for example, students progress from describing the organization of care delivery and analyzing care systems in various health care settings to analyzing national policy issues affecting national systems and evaluating health care systems in other countries.
LINKING CONCEPTS FROM DIDACTIC COURSES TO CLINICAL SETTINGS The conceptual approach extends from didactic courses into the clinical setting, providing an opportunity for students to experience concepts in various clinical applications. These experiences also facilitate the application of concepts to a health care system that is largely based on the specialty model. It is essential that faculty teaching clinical courses help students link concepts from didactic courses to clinical practice settings.
Approaches to Clinical Education There is no question that experiences gained through clinical courses are a crucial part of the curriculum for entry-to-practice nursing programs. Unfortunately, few changes have been made in clinical education during the last few decades, despite obvious limitations to current approaches (12). For example, nearly all nursing programs have experienced challenges in providing clinical experiences in specific settings that lack the ability to accommodate large numbers of students. Nurses in hospital and community settings often feel overwhelmed by large groups of students moving in and out of clinical areas on designated clinical days.
Further, the time-honored clinical placement model in specific population settings with traditional care plans is no longer effective in preparing students for contemporary clinical practice (4,13,14). Students tend to be task oriented in their approach to patient care; developing clinical judgment results from an understanding of patient care on a conceptual level.
The clinical courses in the new curriculum have been designed to address these issues. Unique features of these courses include the integration of populations and practice settings, application of different clinical learning activities, early preceptor experiences, and clinical intensives. INTEGRATION OF POPULATIONS AND PRACTICE SETTINGS Providing experiences with various populations across the age span and in various practice settings throughout the curriculum – as opposed to select courses – is one unique feature of these clinical courses. This approach supports the application of concepts to various population groups and settings and allows students to experience nursing across all continua on an ongoing basis. It is hoped that this approach will translate to an appreciation for the diversity of nursing practice by students and pique interest in multiple areas.
In the first two semesters, students are in clinical courses that combine health promotion and care for individuals with acute and chronic illness in both acute care and community settings such as homes, clinics, community agencies, and schools. There, students are exposed to individuals of all ages. Links between these community and inpatient experiences are facilitated by partnering community and inpatient faculty to work with each clinical group and through the application of concepts in both settings.
CLINICAL LEARNING ACTIVITIES Although clinical courses continue to emphasize patient care in the context of the health care setting, the new curriculum provides opportunities to redesign clinical learning activities. As opposed to the traditional “patient of the day” and “care plan” experiences that have been emphasized in the past, a variety of learning activities and assignments are being explored, including simulation learning and conceptfocused experiences.
The decision to incorporate learning experiences with highfidelity simulators throughout the new curriculum was based on the multiple advantages simulation offers. Simulation is a rich, active learning experience that has been found to increase student motivation and interest and allow students to learn in a safe, risk- free environment (15,16). Simulation learning facilitates the application of concepts learned in didactic courses to specific clinical situations and offers faculty the flexibility to provide for all students specific experiences that cannot be duplicated in real clinical settings. In addition to the development of psychomotor and clinical decisionmaking skills, teamwork, delegation, and communication can be incorporated into the simulation scenario (17).
Concept-focused learning experiences are also being explored for the clinical setting. As an example, assessment of oxygenation and oxygen delivery are featured exemplars for oxygenation in a skills lab course. In the acute and community experiences, students assess oxygenation status and actual or potential interventions, and they identify community resources for individuals in multiple age groups. In clinical conference meetings, students report the various ways they have understood the concept in each of the settings and compare how the concept presents among the various individuals with whom students have interacted.
EARLY PRECEPTOR EXPERIENCES The use of preceptors in undergraduate nursing education is a common practice well documented in the nursing literature. Precepted experiences involve pairing a learner with a nurse clinician and are designed to provide clinical experiences to students on a one-on-one basis. Formal student experiences with nurse preceptors traditionally occur in senior- level clinical courses in the form of a capstone-type experience shortly before graduation.
Because of the excellent experiences reported by students in such a format, the decision was made to begin pairing students with preceptors in the acute-care setting during the first clinical course. Students gain clinical experiences during the times preceptors work; faculty oversee clinical experiences by periodically meeting with students and their preceptors to outline expectations and goals and to clarify assignments. The clinical group meets once a week with the faculty member for clinical conferencing.
Perceived benefits of early precepted experiences include providing students with clinical experiences consistent with contemporary nursing practice, greater opportunity for clinical supervision, and improvement in faculty resources. Successful early preceptor experiences have been recently reported in the literature (18,19).
CLINICAL INTENSIVES Clinical intensives promote in-depth specialty knowledge and skills relevant to specific populations by building on concepts addressed in previous courses. A critical feature of the clinical intensive is student choice; students choose the clinical experiences they wish to take based on their perceived needs or interest. Not only is choice highly valued by students, but it also supports adult learning theory; learners tend to be self- motivated in areas that they value (20,21). Six clinical intensive options are offered: nursing care of children, maternal-newborn, gerontology, mental health, nursing specialties, and high-acuity nursing.
Another perceived benefit of the clinical intensives is increased flexibility in the use of clinical sites and faculty resources. This model alleviates the need for placement of large numbers of students simultaneously in certain clinical sites and allows smaller groups of students to have experiences in very specific clinical areas, such as oncology, rehabilitation, and perioperative nursing.
Web-based Teaching Platform The final unique feature of the new undergraduate curriculum at our institution has been the development and use of a virtual, web-based community that supports learning across all courses in the curriculum. Known as The Neighborhood (22), the community consists of 40 featured characters in 11 fictitious households and supporting community agencies; individuals and family groups residing in the neighborhood represent a variety of health-related issues. Stories about the characters unfold on a week-to-week basis, extending over three semesters, and are enhanced by video clips and photos.
This web-based platform combines case study, storytelling, and narrative pedagogy, providing a theoretical foundation for a conceptual approach, thus facilitating conceptual teaching (22). Because it is used across all courses, students and faculty have shared experiences, allowing for conceptual linking within and among courses.
Furthermore, The Neighborhood is consistent with the new paradigm described by Ibarra (23) as multicontextuality. This concept advances the idea that learners tend to have low-context or highcontext preferences; such preferences are often culturally based on the ways of seeing, interpreting, and communicating meaning from the world. Individuals from many diverse cultural groups (Asians and Asian Americans, Middle Easterners, Africans and African Americans, Native Americans, and Latinos in North America), tend to have high- context preferences (23). Higher education, according to Ibarra, is predominantly a low-context environment. Because The Neighborhood is multicontextual, it is hoped that this platform will facilitate the learning of all nursing students, but particularly minority students.
The Implementation Phase and Its Challenges Curriculum redesign is an overwhelming undertaking. The development of the new undergraduate nursing curriculum at our institution was no exception. A devoted cadre of curriculum revision task force members, reinforced by a supportive administrative team, worked diligently over 18 months, guiding the faculty (many of whom were initially unaware of the need for significant curriculum reform) through the development and approval of the curriculum described in this article.
The implementation phase is proving to be just as challenging because of the complexity and the significance of the changes in the new curriculum. Intense oversight is needed to ensure delivery as planned. As would be expected, concerns have been raised over the loss of certain specialty content. Maintenance of the integrity of the curriculum design, particularly with the addition of new faculty, and evaluation of the effectiveness of this new curriculum are needed.
A second set of challenges is how faculty members teach. Faculty must learn how to teach conceptually and minimize the emphasis on content. They must also learn how to best use The Neighborhood. Because this is an innovative strategy, optimal use will take time. Success of the clinical courses requires acceptance of the new clinical design by our partners in nursing service, development of an adequate pool of qualified preceptors for clinical experiences, and mentorship of adjunct faculty in clinical courses.
Perhaps the greatest challenge that lies ahead will be resisting the temptation to make changes to the new curriculum too quickly. It may take several semesters before problems are accurately identified and fully understood. Clearly, some of the features of the new curriculum may not initially work as well as envisioned, but faculty are committed to the direction this design is taking our college.
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About the Authors Jean Giddens, PhD, RN, is an associate professor at the University of New Mexico Health Sciences Center, College of Nursing, Albuquerque, where four of the other authors are also affiliated. Debra Brady, PhD, RN, is an associate professor, and Mary Wright, MSN, RN, Debra Smith, MSN, RN, and Judith Harris, MSN, RN, are instructors. Pauline Brown, PhD, RN, is an assistant professor at the University of North Carolina, Chapel Hill. Contact Dr. Giddens at [email protected] salud.unm.edu.
Copyright National League for Nursing, Inc. Jul/Aug 2008
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