In today’s world there are multiple factors affecting and challenging institutions of higher education, such as shifting resources; internal influences, including changing faculty and student demographics and institutional mission and governance; and external forces, such as health care reform, change of focus from national health to global health, changing societal demographics, market and employment, discipline and professional associations, and accrediting bodies. One major external force affecting curriculum, the Institute of Medicine (IOM, 2003), established competencies for health professions education that were adapted to nursing education, including patient-centered care, informatics, teamwork and collaboration, evidence-based practice, quality improvement, and safety. Redesign of the work environment of nurses began in 2003 with Transforming Care at the Bedside (TCAB), funded by the Robert Wood Johnson Foundation, with four main components: safe and reliable care, vitality and teamwork, patient-centered care, and value-added care processes. Finkelman and Kenner (2009) discussed the relevance and integration of the competencies to nursing education with development of competencies in knowledge, skills, and attitudes.

Creative, innovative methods of curriculum delivery are being used in an effort to provide cost-effective, quality programming to an increasingly diverse population of students. Flexible curricula are being developed that allow universities to provide programs that quickly respond to the needs of the local, regional, and national constituencies to which they are accountable, including the doctorate in nursing practice (DNP) and clinical nurse leader (CNL). Benefits and risks of changing nursing roles are being discussed and debated (Bargagliotti, 2006; Benner, Sutphen, Leonard, & Day, 2010; Chase & Pruitt, 2006; Cronenwett et al., 2007; Hathaway, Jacob, Stegbauer, Thompson, & Graff, 2006; IOM, 2003; Ironside, 2006; Lancaster, 2006; Lattuca & Stark, 2009; Long, 2004; McCabe, 2006; Porter-Wenzlaff & Froman, 2008; TCAB, 2008). Some authors have asserted that the quickest way to contain university costs and alleviate financial strain is to maintain quality courses yet limit the number of electives offered or to eliminate selected programs of study. At risk is the costly clinical nursing education with a 1:10 faculty-to-student ratio (Fitzpatrick, 2006; IMPAC, 2001).

As institutions of higher education reevaluate how to best achieve their stated missions and position themselves for the future, it is apparent that sweeping changes in higher education are affecting the development and delivery of curricula. Nurse educators in academia also need to be actively involved in exploring cost-effective, comprehensive curricula (American Association of Colleges of Nursing [AACN], 2006; Diefenbeck, Plowfield, & Herrman, 2006; Diekelmann, Ironside, & Gunn, 2005; Fitzpatrick, 2006; Tanner, 2006a, 2006b).

Traditionally, faculty autonomy has been closely tied to curriculum; in fact, faculty are considered to “own” the curriculum. This means faculty are accountable for assessing, implementing, evaluating, and changing the curriculum to assure quality in programs. Monitoring of the “processes and outcomes” to verify currency of the content is a responsibility of the faculty, who must identify problems and offer ideas to resolve the problems. Expert faculty are responsible for mentoring new faculty in the process of teaching curriculum; new faculty are responsible for recognizing whether the program and teaching philosophies are a cultural fit for them. Faculty roles are changing and increasing as curriculum involves more than content, including development of collegiality and integrity among students, establishing clinical partnerships, and advancing with technological changes. A strong knowledge of health care systems is necessary as faculty plan clinicals, provide student supervision, and plan preceptorships in acute care and community-based agencies.

To enhance the success of what has unfortunately become a content-laden curriculum, faculty are becoming more engaged with nurse colleagues in creating evidence-based scenarios and practice opportunities for students to learn the processes of collaboration, inquiry, and “knowing” that are needed to provide safe patient care. Faculty are assuming new teaching roles as high-fidelity simulators, mobile devices, online distance education, and virtual environments accelerate the pace with which students make more sophisticated decisions about complex care. Some faculty are undoubtedly uncomfortable with using these new technologies, not having had previous experience with integrating technology into their teaching practices. Due to rapidly changing societal forces and limited economic resources, faculty will continue to play an important role in curriculum redesign in order to keep curricula contemporary and relevant to practice (Allen & Seaman, 2010; AACN, 2009; Belleck, 2006; Benner et al., 2010; Courey, Benson-Soros, Deemer, & Zeller, 2006; Diekelmann et al., 2005; Frank, Adams, Edelstein, Speakman, & Shelton, 2005; Giddens & Brady, 2007; Jones & Wolf, 2010; Keating, 2006; Larson, 2006; Morris & Hancock, 2008; Nelson et al., 2006; Phillips, Shaw, Sullivan, & Johnson, 2010; Ruth-Sahd & Tisdell, 2007; Skiba, 2006a; Tanner, 2007).

An increase in student diversity provides opportunities and challenges for curriculum development. Students are seeking faster and more economical means of earning a degree in higher education. An increased number of adult students are entering nursing programs as job displacement increases and students have become dissatisfied with their original jobs. The adult students begin the nursing programs highly motivated, goal directed, and expecting to be respected and recognized for their previous successes. An increased number of students with diverse racial and ethnic backgrounds are seeking degrees in nursing and present with diverse learning needs. Universities and nursing programs that expect to survive must respond to the needs of consumers and communities. Curricula must be flexible to accommodate work schedules; offer diversity in courses and programs, including distance education and environments; teach management of culturally diverse people, as well as delegation and negotiation skills; enhance verbal, written, speaking, and information technology skills; and enhance the decision-making skills needed for this increasingly complex world (Allen & Seaman, 2010; AACN, 2009; Belleck, 2006; Doll, 1996; Jones & Wolf, 2010; Morris & Hancock, 2008; Phillips et al., 2010).

Distance education through the Internet has gained popularity as students across the country share ideas in virtual chat rooms, complete discussion board assignments, send electronic papers, and complete quizzes and examinations in online courses without ever seeing the faces of their professors and their colleagues. Educators focus on opening new courses to students; responding to basic and adult students’ learning needs; providing student support resources; and providing well-developed, cost-effective learning materials to distance education students. Potential students compare programs offered through the Internet to determine which will be the best, shortest, and most cost effective (Allen & Seaman, 2010; Cangelosi & Whitt, 2006; Hodson Carlton, Siktberg, Flowers, & Scheibel, 2003; Jones & Wolf, 2010; Melton, 2002; Miklancie & Davis, 2005; Phillips et al., 2010).

To develop relevant nursing curricula for the future, faculty must consider the following questions:

These and other questions challenge nursing faculty to critically review current curricula and methods of instruction with the goal of preparing graduates for the future.

The rapid development of technology has also affected curriculum development, and faculty must be cognizant of the implications of technology in education. How is the development of curricula being affected by the technology explosion? Which programs can be, and should be, offered through the use of online methodologies and other distance-accessible means? The Internet is playing an increasingly larger role in higher education, and students expect the technology to be incorporated into their courses, allowing them flexibility with their coursework that complements their work and family responsibilities. The use of technology also enhances professional education, as enrollment in certification programs that offer advanced knowledge and skills and “just-in-time” opportunities to learn new information will continue to increase and attract learners. Faculty are developing new technology skills to be used for course delivery, testing, curriculum design, and networking among professionals (Benner et al., 2010; Commission on Collegiate Nursing Education [CCNE], 2009; Courey et al., 2006; Diekelmann et al., 2005; Hodson Carlton et al., 2003; Lindeman, 2000).

How are professional curricula, such as nursing and health care, being affected and what are the implications for faculty in redesigning a content-laden curriculum? Restructuring and reforms in the health care system are rapidly changing the focus of nursing curricula, as graduates must learn to deliver care within a health care environment that is focusing more and more on transitional care and the primary health care needs of individuals. Nursing practice must be safe and cost effective across patient care settings. Of course, nursing education must continue to maintain standards and meet the requirements of state boards of nursing and national accrediting agencies while responding to these health care and institutional changes. Nursing curricula need to include the concepts of patient safety, coordination of care, self-management, and health literacy, with emphasis on the burden of health problems on patient and family, strategies to decrease the gap between practice and evidence-based practice, and strategies that are generalizable across populations (Finkelman & Kenner, 2009). Also important to nursing curricula are goals from Healthy People 2020, including a focus on reducing disparities, preventable diseases, disability, injury, and premature death in improving health care for all (Healthy People 2020, n.d.). Forbes & Hickey (2009) reviewed the literature related to nursing curriculum reform, including the effects of the National Council Licensure Examination–Registered Nurse (NCLEX-RN) test blueprint. The NCLEX- RN blueprint is changed every 3 years based on practice surveys, interviews, and other data. As knowledge and practice patterns change, faculty add to the already content-laden curriculum. Forbes and Hickey (2009) noted that the “‘lag’ between current practice and revised examination content contributes significantly to the widening gap between academia and practice” (p. 8).

A decade ago, Lenburg (2002) challenged nurses and nurse educators to consider the following changes that affect the profession and curriculum:

Lenburg’s challenges to the nursing profession are still pertinent today. Nursing education faces a great transformation as faculty strive to adapt curricula to prepare graduates at all levels of education for an increasingly complex workforce that has greater practice expectations and a heavier reliance on the use of advanced technologies (Benner et al., 2010; Commission on Collegiate Nursing Education, 2009). Faculty remain challenged to reconsider curricula with a focus on strengthening student inquiry and teaching concepts across settings (Giddens & Brady, 2007; Tanner, 2007). Traditions in higher education and nursing are changing as faculty progress to more interactive curriculum models that involve students and faculty actively collaborating in the learning process.

Definition of curriculum

The term curriculum was first used in Scotland as early as 1820 and became a part of the education vernacular in the United States nearly a century later. Over time, curriculum—derived from the Latin word currere, which means “to run”—has been translated to mean “course of study” (Wiles & Bondi, 1989). Ronald Doll (1996) defined curriculum as the “formal and informal content and process by which learners gain knowledge and understanding, develop skills, and alter attitudes, appreciations, and values under the auspices of that school” (p. 15). William Doll (2002) described curriculum in relation to a shifting paradigm, moving from a formal definition to a focus on one’s multiple interactions with others and one’s surroundings. He defined curriculum using the following five concepts:

1. Currere: “To run a course . . . a process or method of ‘negotiating passages’—between ourselves and the text, between ourselves and the students, and among all three” (pp. 45–46).

2. Complexity: “Looking at curriculum . . . as a complex and dynamic web of interactions evolving naturally into more varied interconnected forms is a formidable task that will require vision and perseverance” (p. 46).

3. Cosmology: Viewing the curriculum as alive, combining “the rigorousness of science . . . the imagination of story . . . the vitality and creativity of spirit” (p. 48).

4. Conversation: “Teachers and students respect, honor, and understand their own humanness . . . the ‘otherness’ of each other . . . [and] the texts studied and the ways of thinking inscribed in them” (pp. 49–50).

5. Community: “An extension of community beyond self,” which will include “ecological, global, and cosmological issues within which all humans are enmeshed” (pp. 51–52).

Because of the amorphous nature of the term curriculum, it has a variety of definitions. Educators prefer particular definitions based on individual philosophical beliefs and the emphasis placed on specific aspects of education. A review of literature revealed that common components in the definition of curriculum include the following (Beauchamp, 1968; Doll, 1996; Longstreet & Shane, 1993; Ornstein & Hunkins, 1993; Wiles & Bondi, 1989):

• Preselected goals and outcomes to be achieved

• Selected content with specific sequencing in a program of study

• Processes and experiences to facilitate learning for traditional and adult learners

• Resources used

• The extent of responsibility for learning assumed by the teacher and the learner

• How and where learning takes place

Curriculum can be viewed from a variety of perspectives, ranging from narrow and circumscribed to broad and encompassing. Oliva (1992) and others offered additional varied interpretations of curriculum as follows (Doll, 1996; Erickson, 1995; Klein, 1995):

• Knowledge organized and presented in a set of subjects and courses

• Modes of thought

• Cognitive and affective content and process

• Instructional set of outcomes and performance objectives

• Everything planned by faculty in a planned learning environment

• Interschool activities, including extracurricular activities, guidance, and interpersonal relationships

• Individual learner’s experience as a result of schooling

Curriculum development in nursing

Curriculum in nursing has also been viewed from a number of perspectives. Heidgerken, a respected nurse educator in the 1940s and 1950s, believed that curriculum entailed all planned and day-to-day learning experiences of the students and faculty, including both organized instruction and clinical experiences (Diekelmann, 1993). Taba (1962), a curriculum expert whose work influenced nursing education, defined curriculum as the following:

All curricula, no matter what their particular design, are composed of certain elements. A curriculum usually contains a statement of aims and of specific objectives; it indicates some selection and organization of content; it either implies or manifests certain patterns of learning and teaching, whether because the objectives demand them or because the content organization requires them. Finally, it includes a program of evaluation of the outcomes (p. 11).

Building on curriculum as a plan, Beauchamp (1968), another expert in curriculum development, viewed curriculum as a written document depicting the scope and arrangement of a projected educational program for a school.

For the past 25 years, nurse educators have been greatly influenced by the work of Bevis. The definition of curriculum used in her earlier writings reflected her allegiance to the Tyler behaviorist, technical model of curriculum development, an orientation supported by most nurse educators at the time. In 2000 Bevis defined curriculum as “those transactions and interactions that take place between students and teachers and among students with the intent that learning takes place” (p. 72). Bevis challenged nurse educators to move from what she termed the Tylerian/behaviorist curriculum development paradigm to one that focuses on human interaction and active learning. Relative to this new paradigm, Bevis proposed that the definition of curriculum be changed to incorporate students’ and teachers’ interactions and the transactions that occur (Bevis, 1989, 2000).

Other nurse educators have attempted to broaden Bevis’ definition of curriculum. To capture the personal meaningfulness of curriculum, Nelms (1991) defined the term as intensely personal learning within a transpersonal interaction, stating that curriculum is “the educational journey, in an educational environment in which the biography of the person (the student) interacts with the history of the culture of nursing through the biography of another person (the faculty) to create meaning and release potential in the lives of all participants” (p. 6).

The nursing curriculum is often based on current practice, accreditation standards, regulation requirements, and faculty interests, which leads to lack of standardization of curricula. Dialogues among nursing educators about the conceptualization of curriculum include challenges to traditional ways of designing curricula in which curricula often follow practice. “It is the responsibility of nursing education in collaboration with practice settings to shape practice, not merely respond to changes in the practice environment” (AACN, 1999, p. 60). New opportunities abound to foster collaborative debate and dialogue on a number of issues, including how to accomplish the following:

• Enhance students’ delegating, supervising, prioritizing, clinical decision making, and leadership skills to effect change.

• Focus on health promotion, disease prevention, and health care disparities across health care settings.

• Enhance student–faculty–preceptor interactions in the learning process.

• Design clinical models that allow for student immersion in the practice setting.

• Use “anticipatory–innovative learning” rather than “maintenance learning” (Watson, 2000, pp. 40–41).

• Use evidence-based research and nursing practice.

• Integrate culture of safety concepts in specifically designed interdisciplinary practices.

• Focus on quality, cost-effective patient-centered care.

• Expand culturally sensitive nursing practice in community-based agencies.

Although various curriculum models are found in the literature, most authors in nursing education agree that for learning to be successful and satisfying, an ongoing, responsive relationship between curriculum and instruction is essential (Baldwin & Nelms, 1993; Benner et al., 2010; Commission on Collegiate Nursing Education, 2009; Keating, 2006; Morris & Hancock, 2008; Morse & Corcoran-Perry, 1996; Wink, 2003).

Types of curricula

Regardless of the interpretation of curriculum, several curricula may occur concurrently. The official curriculum includes the stated curriculum framework with philosophy and mission; recognized lists of outcomes, competencies, and learning objectives for the program and individual courses; course outlines; and syllabi. Bevis (2000) stated that the “legitimate curriculum . . . [is] the one agreed on by the faculty either implicitly or explicitly” (p. 74). These written documents are distributed to other faculty members, students, curriculum committee members, and accrediting agencies to document what is taught.

The operational curriculum consists of “what is actually taught by the teacher and how its importance is communicated to the student” (Posner, 1992, p. 10). This curriculum includes knowledge, skills, and attitudes emphasized by faculty in the classroom and clinical settings.

The illegitimate curriculum, according to Bevis (2000), is one known and actively taught by faculty yet not evaluated because descriptors of the behaviors are lacking. Such behaviors include “caring, compassion, power, and its use” (p. 75).

The hidden curriculum consists of values and beliefs taught through verbal and nonverbal communication by the faculty. Faculty may be unaware of what is taught through their expressions, priorities, and interactions with students, but students are very aware of the “hidden agendas” (curriculum), which may have a more lasting impact than the written curriculum. The hidden curriculum includes the way faculty interact with students, the teaching methods used, and the priorities set (Bevis, 2000; Posner, 1992; Schubert, 1986).

The null curriculum (Bevis, 2000; Eisner, 1985; Schubert, 1986) represents content and behaviors that are not taught. Faculty need to recognize what is not being taught and focus on the reasons for ignoring those content and behavior areas. Examples include content or skills that faculty think they are teaching but are not, such as critical thinking. As faculty review curricula, all components and relationships need to be evaluated.

The idea of an interrelationship between curriculum and instruction is also supported by other educators, and is not a new concept. In 1996, Lempert advocated that a new approach to education and curriculum must be developed, one in which faculty were active participants and guides in learning, not lecturers. Lempert urged an increased involvement in the community, with the university becoming responsible and accountable to the needs of the community. He also favored a curriculum that recognized and accepted individual differences to enhance multiculturalism. He believed that curriculum and learning should be focused on acquiring skills, not just factual knowledge. After all, knowledge should be measured by the ability of the students and graduates to perform, not recite facts. Therefore he argued that the most effective learning occurs by experience, not just by passively learning facts. These thoughts, while introduced more than 15 years ago, are still pertinent to the design of nursing curricula today.

General education and nursing curricula are becoming more integrated, with classroom and workplace joining to meet learning goals set by diverse groups of students. Students must develop the ability to communicate across cultures; understand and respect others’ views and lives; and learn teamwork skills, including management, delegation, and negotiation. The curriculum should offer activities to enable students to gain actual experiences and learn to work collaboratively with other disciplines in seeking solutions to problems (Balakas & Sparks, 2010; Benner et al., 2010; Dacey, Murphy, Anderson, & McCloskey, 2010; Porter-Wenzlaff & Froman, 2008). The concept of service learning, which embodies these principles, is further discussed in Chapter 12.

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