Curriculum designs

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Curriculum designs


Donna L. Boland, PhD, RN, ANEF and Linda M. Finke, PhD, RN


Curriculum, by its very nature, holds a different element of promise for different groups of stakeholders. Traditionally, curriculum is a product to be delivered. For stakeholders focusing on consumerism, curriculum is a product that should be available for purchase at a fair market value with explicit outcomes noted. There are also those with a gestalt view who believe that curriculum is to be experienced and that what is learned can be interpreted only from the perspective of the learner and that is the true value of the educational experience. No matter how one defines curriculum, the concept should be “sufficiently inclusive and dynamic to account for the many innovations that involve instruction methods, sequencing, and assessments as well as instructional goals and content, all of which have been implemented to improve learning” (Dezure, 2010).


A well-conceived curriculum is critical to the preparation of practicing nurses at all levels. Curricula in general and undergraduate curricula specifically have been under scrutiny for the last decade. There have been a number of reports since the 1980s that have been critical of higher education, suggesting that reform is needed if graduates are to meet the expectations of business and industry (Dezure, 2010). These calls for reform led to four major initiatives of the 1990s that included the introduction of learning outcomes in the language of competencies, emphasis on integration of learning experiences, focus on enhancing learning, and growth in learning from a more global perspective (Dezure, 2010). Today the priority for learning is not so much on what is learned, as much as it is on what graduates can do with their learning. For nursing, the curriculum must prepare graduates to function in a dynamic and increasingly complex environment.


O’Neil (2009) speaks to transformational changes that will require students to learn how to apply knowledge in emerging care systems that are and will continue to be ill defined. The challenge facing nurse educators is how to reenvision curriculum to prepare nurses to practice in a system that will continue to change and evolve well into the future. Tanner (2010) suggests that the critical questions that curricula design need to address are what must be taught, how to teach it effectively and efficiently, and where teaching and learning occur to achieve the best outcomes. Dezure (2010) indicates that the curriculum shifts that shape curricula today are the move to broad learning competencies from a narrower focus on mastery of learning specific content, a shift to more integrative learning experiences from those that emphasize specific skill sets, and an exploration of innovative teaching practices beyond the traditional pedagogical approaches designed to deliver subject matter.


Regardless of the view held about general education or professional education, the underlying theme is that curriculum must be designed to be responsive to the needs of today’s and tomorrow’s society. Within the nursing profession, curricula design must reflect the current health care system and be fluid and flexible. These curriculum changes follow Bevis’ (1988) original call for a curriculum transformation. Bevis called for a:




More recently, the profession has faced continued calls for radical curriculum transformation to best prepare nurses who are equipped to practice and lead in evolving health care systems (Benner, Sutphen, Leonard, & Day, 2010; Institute of Medicine [IOM], 2010). This transformative process needs to focus on how to design or revise curricula without using an additive process that continues to overload the curriculum with content (Benner et al., 2010).


Faculty have historically viewed curriculum revisions that meet student learning needs from a content perspective rather than a context perspective. As new technologies emerge, new evidence is discovered, and new best practices are identified, they are packed into a curriculum structure that is already saturated with content. Curricula in most nursing programs today are at the breaking point. Instead of simply continuing to add content to the curriculum, the challenge for faculty is to determine what students need to know to survive and prosper in a dynamic health care system driven by uncertainties and shifting priorities, and how best to design learning experiences that will facilitate acquisition of those competencies. According to O’Neil (2009), nursing faculty will need to revise curricula to accommodate a “shift from hospital based care to community based care” (p. 319). This shift will require faculty to redefine what we have identified as traditional competencies critical to the practice of nursing “within the context of community-based and consumer responsive care services” (p. 319). This process of envisioning and rethinking nursing curricula will require us to generate new models of educating the next generation of nurses.


This chapter discusses the issues of undergraduate and graduate education that have historically had an impact on program and curriculum designs, as well as current designs for all levels of nursing programs. It is important to have a sense of the issues that have shaped and continue to shape nursing curricula as faculty make decisions about the design of curriculum in their programs.




Undergraduate education in nursing




Constituencies invested in undergraduate curriculum design

Traditionally, undergraduate nursing curricula are assumed to set the stage for entry into nursing practice and to provide a foundation essential to graduate education and advanced nursing practice. However, as transformative discussions continue, there is increasing concern as to what level of educational preparation is needed to prepare nurses for an evolving health care system. Designing curricula that facilitate the academic progression of the nursing workforce (National League for Nursing [NLN], 2011a) will be imperative to achieve the recommendations set forth in the IOM (2010) report on the future of nursing that call for increasing numbers of baccalaureate and advanced degree–prepared nurses. Emerging from these conversations is the need for expanding knowledge and skill sets to meet increasing responsibilities and complexities related to work and work settings.


The increase in public accountability has expanded the visibility of nursing education at the national, state, and local levels, which has ultimately increased stakeholder involvement in the education and practice of nurses. Given the many different constituencies that are invested in the outcomes and products of undergraduate nursing programs, there has been an increase in the number of often competing controls on the development, implementation, and evaluation of undergraduate curricula. As a professional educational degree program, nursing is seemingly among the most regulated educational enterprises on campuses of higher education today. One advantage of regulation for nursing programs is the high level of scrutiny to which they are subjected. A disadvantage to this level of control is the perceived decrease in latitude to be unique and creative in the design and delivery of the curriculum. Some of this regulation stems from the high level of accountability to produce graduates with the knowledge and skills required to practice and the pressures to produce more nurses in a quicker and more efficient manner in the face of shrinking resources. In this reality the emphasis is on outcomes achieved, not the process leading to those outcomes.



State boards of nursing

The first constituents interested in nursing education programs and curricula are the individual state boards of nursing. Early in the history of state boards of nursing, rules and regulations were set for programs that often specified content areas that must be covered, minimum hours that must be spent by all students in specified health care areas, and competencies or skills that all students must possess at the completion of a nursing program leading to licensure. Although these rules and regulations have tended to become less prescriptive, they are still state specific and varied. Today, state boards are also involved in issues related to evolving teaching pedagogies being driven by technological advances, the constitution of clinical learning experiences, faculty credentialing, and advanced practice nursing. However, state rules and regulations are still primarily focused on overseeing the implementation of undergraduate nursing curricula. The establishment of state regulations stems from the need to hold licensed health care personnel to standards of social responsibility and public accountability for actions taken on behalf of others. It can be argued that the education of nurses is and should be independent of regulatory licensure agencies, whose sole interest should be the protection of the consumer of nursing services, but many state boards of nursing continue to hold significant regulatory control over undergraduate programs. It is apparent that these regulatory controls can be perceived to affect the creativity and flexibility that nursing faculty have within nursing programs, especially with regard to undergraduate curricula. Some state boards are actively engaged in conversations as to what constitutes acceptable alternative learning experiences and how much of these alternative learning experiences are acceptable within the curricula. These alternative experiences include preceptor and simulated experiences. It is anticipated that the growth in the creation of alternative or nontraditional learning experiences will continue as faculty seek innovative ways of delivering learning to an increasingly diverse population of learners.



Accrediting bodies

Other constituents interested in nursing education programs are accrediting bodies. The NLN historically served the role of the professional accrediting body for the evaluation of undergraduate nursing programs. Through the establishment and refinement of program assessment criteria, the NLN also affected the development, implementation, and evaluation of undergraduate nursing curricula across the country for a number of decades. These criteria, which address the mission and governance of the institution, faculty, students, curriculum, resources, and program effectiveness, had to be met by all programs seeking or renewing accreditation. The curriculum was developed by the nursing faculty and provided learning experiences consistent with the nursing unit’s mission and stated outcomes of the program. The National League for Nursing Accrediting Commission (NLNAC) was established in 1996 to act as an independent body that would carry out the accreditation activities that were once controlled through the NLN. The NLNAC continues to accredit all levels of nursing curricula and has identified standards by which program effectiveness and student achievement can be measured. Today, student academic achievement is measured against graduation rates, performance on licensure examinations, job placement rates, and program satisfaction (NLNAC, 2008).


The Commission on Collegiate Nursing Education (CCNE) entered the arena of professional accreditation in 1997 and began accrediting baccalaureate and graduate nursing programs. Unlike the NLNAC, with its broad accreditation scope, the CCNE focuses its accrediting efforts on baccalaureate and higher degree programs exclusively. This commission has also identified standards for judging the degree to which nursing programs meet these published expectations. Student achievement is still very much a priority for this accreditation body and the focus of its updated 2009 Standards for Accreditation of Baccalaureate and Graduate Degree Nursing Programs (CCNE, 2009).


Although accreditation criteria are not meant to be prescriptive, they are becoming more so as the U.S. Department of Education becomes more explicit in its emphasis on outcome data specified in its standards for accrediting professional accreditation associations (U.S. Department of Education, 2010). Nursing faculty have a tendency to use professional standards in shaping curricula. Although this is not the explicit intent of accreditation criteria, it is a reality. Traditionally, the effect of accreditation standards can be seen in the balance between nursing and general education distribution credits, the sense of a need for theoretical frameworks on which to design curricula, the need for rationale for course sequencing, and credit hour limits. As an example, one can look to The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008) as an example of how accrediting bodies are and will continue to influence program development and curricula design. See Chapter 28 for additional information about curriculum evaluation and Chapter 29 for a further discussion of the accreditation process.



Institutions of higher education

Historically, nursing has been viewed as having or needing regulatory oversight from those outside its discipline. Institutions of higher education that house nursing programs often actively influence the development and implementation of nursing curricula. This involvement takes many forms, including the development of general education requirements, procurement of clinical sites, hiring of teaching faculty, defraying the cost of undergraduate nursing education, supporting faculty practice, monitoring distance education offerings, and equipping learning resource centers to keep pace with the advances in technological support for teaching and learning. Higher education institutions have often based funding formulas on enrollment patterns. Historically, these funding formulas have led to increases in recruitment efforts, expansion of existing programs, and the addition of new programs. More recently, state funding decisions for higher education institutions are placing increasing emphasis on outcome productivity. This shift in priorities places more value on the retention and graduation of students in a timely fashion, the employment patterns (which includes numbers employed, time between employment and graduation, distribution of employed graduates), and employer satisfaction with graduates’ abilities to meet stated expectations.


Curricula are also being transformed to meet the needs of more nontraditional students or students with unique needs, leading to more creativity and flexibility in curriculum construction and delivery. The expected outcome is to entice, retain, and graduate a diverse population of students.



Market forces

The marketplace also has a strong voice in the design and implementation of nursing curricula. The first schools of nursing were hospital-based and generally administered by the director of the hospital, with direct supervision of the students being delegated to the nursing staff affiliated with the institution. Class content was identified and taught by medical staff members, who had a large investment in what these young nursing students were being prepared to do. This strong voice has changed in both tone and expression over the last 100 years. Today, nursing educators collaborate with their nursing practice counterparts in the design, implementation, and evaluation of nursing curricula. The challenge facing nursing educators and practicing nurses is to design and deliver curricula that meet expectations for those entering today’s practice arena while equipping graduates with the skills and competencies necessary to adapt to anticipated demands of the future.


The marketplace is also affecting curriculum design and delivery as nursing faculty look for economical ways of preparing students. Consumers (students) are looking for quality education at an affordable price. Students no longer expect to fit into rigidly designed curricula but look for curricula that can be shaped around their needs as learners. There is recognition that students bring different experiences and interpretation of those experiences to the learning environment. These students, with their varied experiences and expectations, perceive more dissatisfaction with a highly structured curricula and a one-size-fits-all pedagogical approach to learning (Umbach & Kuh, 2006).



Organizational forces

There are many organizational forces that affect undergraduate curricula. For example, professional organizations such as the American Nurses Association and AACN set forth professional standards that are used to guide undergraduate curriculum development. In another example of organizational influence, the American Organization of Nurse Executives’ (AONE) (2004a) board of directors released the AONE Guiding Principles for the Role of the Nurse in Future Patient Care Delivery Toolkit, which outlined the work of the nurse in the future. They envisioned the work of nurses as becoming increasingly complex and challenging and forecast that nurses would need to be educationally prepared for this increasing complexity. Given this view, the AONE membership supports the transition of educational preparation of nurses to the baccalaureate level, assuming that this level of education will “prepare nurses of the future to function as an equal partner, collaborator and manager of the complex patient care journey” (AONE, 2004b). The impact on undergraduate education means a revolution of the current educational structure and our approach to the education of our students. The AONE’s guiding principles were updated in 2010 (AONE, 2010).


Another example of organizational influence is the IOM’s 2001 report that called for a fundamental change in how health care is being delivered, indicating that the current health care system was not meeting the care needs of many. In this report the IOM asserted that to address systematic failings, the health care system must be focused on improving the safety of care; providing care that is grounded in scientific knowledge, patient-centered, focused on quality improvement, informatics-driven, and cost effective; delivering care in an acceptable time frame to avoid waste in time and energy; and demonstrating equity in distribution and quality of care (IOM, 2001). To meet these critical initiatives, the educational preparation of the workforce would need to be changed to incorporate new skills and competencies (IOM, 2003). In response to these initial IOM reports, the challenge to nursing programs was to adapt curricula to ensure that graduates were being prepared with these competencies.


Recently, the 2010 IOM report, The Future of Nursing, was released and is expected to have a major impact on both the practice and the education of nurses into this next decade. This report was released at a time when the United States is facing one of the largest health care reform movements of the last several decades. This reform movement is expected to shift the competencies nurses will need to practice in new and redesigned practice models.



Historical implications for understanding undergraduate curricula

Florence Nightingale has been credited as the founder of modern nursing. As a prolific writer who spoke in eloquent tones about the education and practice of nurses, Nightingale envisioned nursing as more than the understanding of disease. She is quoted as having said, “Pathology teaches the harm that disease has done. But it teaches nothing more” (Nightingale, 1969, p. 133). Her nursing orientation focused on health as a broad and encompassing concept that requires an understanding of human nature and the ability of that nature to affect individual health. Nightingale’s thinking that nurses need to acquire an understanding of the science and art of human existence has continued to permeate undergraduate education from its original, hospital-based training programs to its current degree-granting educational programs.


Traditionally, nursing philosophy and theory are crucial to nursing curricula because philosophy and theory state what nursing is and what it should be. Salsberry (1994) stated that “philosophy of nursing identifies what is believed to be the basic or central phenomena of the discipline, relates nursing to a particular world view, and provides some information on how one may come to learn about the world” (p. 13). Nursing theorists, starting with Nightingale, have provided nursing with the theoretical foundation for educational philosophies, mission statements, curriculum models, and delivery of curriculum content. Despite differing beliefs posited among recognized nursing theorists, they, like the curriculum models that have been predicated on their thinking, have focused on the nature of humans, society, and nursing practice. It appears that the previous emphasis on the roles of nursing philosophy and theory in design of nursing curricula is decreasing as the emphasis has shifted to one that is more outcome-driven.


The focus on human beings and their society complements the aims of general education that date back to Hellenic times, when education examined both “human nature and the nature of society” (Brubacher & Rudy, 1976, p. 287). The desire to understand human nature and society is still a prevailing factor in shaping current undergraduate curricula, especially nursing curricula. However, the phenomenological lens is now being expanded to include the learner as we focus on understanding human nature. This broader focus encompasses the individual learner’s desires and abilities to shape the learning experience through inquiry, reflection, and questioning assumptions about human nature and society (Cranton, 2006). It is this individual understanding that drives the learning process and through which nurses will filter their understanding of human nature and society as a liberally educated person. An example of how curriculum design can be used to foster an understanding of human nature and society can be found in Georgetown University’s Bring Theory to Practice demonstration project, which has focused on infusing its undergraduate curriculum with community-based learning experiences around real-life issues that college students were facing (Riley & McWilliams, 2007).



Undergraduate program designs

The design and development of undergraduate nursing programs that reflect the mission of the university or college, the philosophy of the faculty, current and projected nursing practice trends, changes in the health care system (both real and theorized), changes in the demographics of the potential learner pool, and stakeholders’ expectations require creativity, political savvy, negotiation skills, analytical rigor, psychic energy, and a modest amount of altruism. Faculty involved in designing programs and building curricula must possess a clear sense of purpose, a commitment to procuring resources, an understanding of market forces, the ability to anticipate health care trends of the future, and the ability to know when goals have been accomplished. Once programs are designed, curriculum building becomes a never-ending task that is indispensable to, but separate from, the acts of teaching and learning. Curriculum is a dynamic, evolving entity shaped by learner needs and faculty’s beliefs about the science and art of nursing.



Factors affecting program design

With the current emphasis on student learning and student engagement, it is important that curricula be designed to promote the development of individual students. This can be accomplished in part by encouraging interrelationships among the learners, faculty, and what is being learned. Additional factors affecting program design and student development include focusing on health and well-being of society; grounding learning in contemporary evidence; creating a learning environment that is infused with experientially and culturally based learning opportunities; and supporting individual creativity especially as it relates to inquiry, problem solving, and reflection.


When creating nursing curricula for the twenty-first century, Glasgow, Dunphy, and Mainous (2010) recommend that curricula be focused on the integration of science and research and the influences resulting from health care policies. These authors envision curricula that cut across various disciplines exposing students to interdisciplinary collaboration and teamwork. Curricula need to be “well grounded in disease prevention, health promotion and screening, and public health, aging and older adults, ethics, genetics, public speaking, and writing skills” (p. 356). Technology also plays a crucial role in the delivery of the curriculum.


Benner et al.’s (2010) work on transforming nursing education to some degree complements the recommendations of Glasgow et al. Grown out of her research efforts, Benner has identified four “shifts” that should guide curriculum design based on the evidence she has collected:







Arhin and Cormier (2007) argue that a deconstruction approach to learning is more compatible with the postmodern generation of learners. The implications of this theoretical approach to curriculum design support the notion that curricula be less content weighted and more about the interpretation the learner searches for within the knowledge to which they are exposed.


The guiding principles that AONE identified are more prescriptive in nature than Benner et al. or Arhin and Cormier but also need to be taken into consideration when designing undergraduate curricula, especially those that lead to a baccalaureate degree. These guiding principles include the following (AONE, 2010):



• At the core of the work of nurses is knowledge and caring.


• Care is patient-centered and family oriented.


• Nurses need to know how to access knowledge and appropriately use that knowledge in the management of care.


• Accessed knowledge will need to be critically synthesized in the complex management of care.


• Nurses’ knowledge will be grounded in the understanding of patient populations that include the concepts of generations, diversity, and interdependency.


• Nurses deliver care by creating relationships that include patients and interdisciplinary colleagues.


• Nurses will partner with patients in managing their care journey in the context of individual needs, desires, and resources.


• The concepts of quality and safety are core to the delivery of nursing care.


In translating some of the expectations of the IOM work into nursing curriculum operating principles, faculty will need to focus on improving the health and functioning of people; prepare students to deliver health care in a safe, effective, patient-centered, timely, efficient, and equitable fashion; and develop competencies to establish care benchmarks and evaluate the outcomes of care according to these benchmarks (IOM, 2001, 2010).


Various types of undergraduate nursing programs have been developed to allow multiple entry points into the profession. Generally there are many similarities among program designs, with variations occurring within the internal configuration of courses and course content. The three most common traditional program designs are the two-year associate degree, the four-year baccalaureate degree, and the three-year diploma program. In addition to these three educational models, there are accelerated baccalaureate programs, as well as accelerated graduate degree nursing programs for those students who hold a previously earned nonnursing degree. For example, students with previous nonnursing academic degrees may choose to pursue an accelerated or generic master’s degree program, a clinical nurse leader program, or accelerated pathways leading to doctoral studies. Diploma, associate, and baccalaureate degree program designs are discussed in further detail in this section, as are licensed practical (vocational) nursing programs.


The doctorate in nursing practice (DNP) program and the PhD program are discussed in the graduate section of this chapter, as is the clinical nurse leader (CNL) program, which is currently being implemented primarily as a graduate program. As the nursing shortage continues to be of great concern, there is a national call to develop transitional or bridging programs that promote the academic progression of nurses from one educational degree level to another in an expedited fashion (IOM, 2010). These innovations share three main characteristics: a focus on decreasing the time to move from one academic degree to another, recognition for prior educational and practical or life experience, and the ability to transport educational credit.



Licensed practical (vocational) programs

Licensed practical nursing (LPN) programs, also known as licensed vocational nursing (LVN) programs in some regions of the country, provide an opportunity for many individuals to first enter the nursing workforce. LPN programs are typically one year in length and are taught in community colleges and vocational schools. LPNs are employed in structured environments, with approximately 25% employed in hospitals, 28% in long-term care, and 12% in physician offices (U.S. Bureau of Labor Statistics, 2009). It is estimated that the demand for LPNs is expected to grow 21% between 2008 and 2018, mostly due to the anticipated increase in long-term care health care needs (U.S. Bureau of Labor Statistics, 2009). Individuals who are first licensed as LPNs frequently return to school to pursue licensure as registered nurses, thus increasing their levels of responsibility and accountability within the health care environment. Providing avenues of academic progression for LPNs that recognize their previous learning and experience will continue to be an important component of nursing education mobility programs.

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Feb 12, 2017 | Posted by in NURSING | Comments Off on Curriculum designs

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