245CHAPTER 11

Curriculum Planning for Baccalaureate Nursing Programs

Peggy Wros

Pamela Wheeler

Melissa Jones

OBJECTIVES

Upon completion of Chapter 11, the reader will be able to:

OVERVIEW

Chapter 11 provides an overview of the process of curriculum development for baccalaureate nursing programs. It reviews the utilization of the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008b) in curriculum development and discusses fast track programs and RN to BSN programs. This chapter summarizes the advantages and challenges related to residency/externship programs for the new graduate. The following outlines the content of the chapter.

WHEN IS IT TIME FOR CURRICULUM CHANGE?

Nursing is at the crossroads of major societal changes in health care reform, technology, and educational accountability, and the Institute of Medicine (IOM) has recommended an increase in the number of baccalaureate prepared nurses (IOM, 2010). The population of the United States is becoming more diverse, the income gap is widening, and baby boomers are aging. Veterans are returning from war and the country is experiencing a prolonged recovery from the economic recession. All of these factors affect the kind of programs that are offered at schools of nursing, the content of the curricula, and the way that faculty teach in nursing education.

In order to prepare graduates of prelicensure nursing education programs for practice in an ever-changing health care environment, baccalaureate nursing curricula must be revised or updated on a regular basis. Nursing schools rely on a robust evaluation plan to provide information that guides curriculum revision. In addition, there are compelling factors external to individual nursing programs that influence the need for curricular change within baccalaureate nursing programs across the country. These are reflected in the Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008b) and include expressed concern with the quality of prelicensure nursing education by health care organizations, advances in education and health technology, and educational research that identifies more effective teaching–learning strategies.

THE BACCALAUREATE ESSENTIALS

The Essentials (AACN, 2008b) reflect current priorities in: (1) health care, including expanded emphasis on quality and safety, patient technology, patient-centered care, population health, health care regulation, and globalization; (2) nursing 247education, with a focus on the liberal arts and information management; and (3) professional nursing practice, which is grounded in evidence-based practice, interprofessional communication and collaboration, and enduring social values. See Table 11.1 for a list of the Essentials (AACN).

TABLE 11.1 THE ESSENTIALS OF BACCALAUREATE EDUCATION FOR PROFESSIONAL NURSING PRACTICE

Online learning is increasingly integrated into nursing education, although application of web-based approaches varies widely between nursing programs. Quality 249standards, such as Quality Matters (www.qualitymatters.org), have been developed for online education and faculty development and instructional design support are essential to ensure the effective delivery of online coursework (Anderson & Tredway, 2009; Little, 2009). The web-enhanced classroom can be used to supplement learning through online activities such as discussion boards, resource-sharing, exams, videos, or other virtual programming (Creedy et al., 2007). While specific nonclinical courses may be taught online or offered as an alternative method of delivery in prelicensure programs, they may be the primary pedagogy for baccalaureate completion programs (Anderson & Tredway, 2009). Distance applications include electronic classrooms and videoconferencing that facilitate inclusion of rural students and teaching across college campuses, or to facilitate supervision for students involved in off-site practicum experiences. New software applications are proliferating and significantly expand the resources available for educators. The availability of distance education technologies and the related philosophy of an academic institution toward their use as a teaching–learning methodology have significant implications for the curriculum development.

High-Fidelity Simulation

While nursing educators have long employed low- and mid-fidelity simulation in nursing skills labs, high-fidelity simulation has become the “gold standard” as schools of nursing incorporate this teaching strategy into curricula to prepare students for clinical experiences and to supplement or replace clinical hours. Using this technology, faculty can create standardized and realistic clinical learning activities that ensure that all students get experience with critical patient-care situations in a variety of health care settings, including mental health and community, in a low-risk and supportive environment (Nehring, 2008). High-fidelity simulation has the potential to improve student knowledge, skill performance, clinical reasoning and judgment, role identity, and self-confidence (Cordeau, 2012; Harder, 2010; Ironside, Jeffries, & Martin, 2009; Sinclair & Ferguson, 2009). Simulated learning experiences can be developed to support the progressive achievement of curriculum outcomes by intentionally spiraling core concepts and skills throughout the curriculum in increasingly more complex scenarios (Dubose, Sellinger-Karmel, & Scoloveno, 2010). Interprofessional simulations can provide an opportunity for students to learn about teamwork and collaboration and the roles of other health care professions (Baker et al., 2008; Buckley et al., 2012; McGuire-Sessions & Gubrud, 2010; Reese, Jeffries, & Engum, 2010; Riesen, Morley, Clendinneng, Ogilvie, & Murray, 2012; Scherer, Myers, O’Connor, & Haskins, 2013).

It must be noted, however, that there is little evidence regarding how high-fidelity simulation compares to traditional clinical approaches, and it is fairly costly and time intensive for faculty (National Council of State Boards of Nursing [NCSBN], 2009). Depending on the goal of instruction, lower fidelity simulation can be an effective alternative (Sharpnack & Madigan, 2012). Simulation using live actors as standardized patients is also a powerful strategy with the potential to change attitudes, beliefs, and behaviors among student participants (Bornais, Raiger, Krah, & El-Masri, 2012; Luctkar-Flude, Wilson-Keates, & Larocque, 2012; Noone, Sideras, Gubrud-Howe, Voss, & Mathews, 2012; Ward, Cody, Schaal, & Hojat, 2012).

250The focus in simulation in nursing education has been primarily on learning, including prebriefing and debriefing, with less emphasis on more high-stakes summative evaluation (Cordeau, 2012). In planning for use of simulation in a curriculum, schools are advised to check with their State Board of Nursing regarding regulations for percentage or replacement of clinical hours with high-fidelity simulation (Nehring, 2008). In order to make the best use of this technology, simulation must be approached with vision and intention in the curriculum development process (Harder, 2010).

THE LEARNING-CENTERED PARADIGM

There have been significant advancements in educational research that improve understanding of how students learn. For over a generation, college educators have developed innovative approaches to interactive learning in higher education and there is a significant body of knowledge that provides evidence for the effectiveness of these practices (American Association of Colleges and Universities, 2007). Over a decade ago, Weimer (2002) described a paradigm shift in learning-centered education in which the power in the classroom is shared between teacher and students, content becomes less important than the reflective construction of knowledge, teachers become coaches, students assume responsibility for their learning, and authentic learning assessment is incorporated into the curriculum.

Nurse educators have made a case for moving away from the traditional content-laden behaviorist paradigm to a constructivist learning-centered model in which students are active participants. The traditional lecture and testing approach to instruction has been expanded to include narrative pedagogies, such as storytelling, reflective journaling, and literature interpretation (Brown, Kirkpatrick, Mangum, & Avery, 2008; Diekelman, 2005), cooperative or team-based learning (Andersen, Strumpel, Fensom, & Andrews, 2011; Hanson & Carpenter, 2011), and problem-based learning (Williams, 2001; Yuan, Williams, & Fin, 2007). Faculty are “flipping the classroom” by assigning readings and online lectures as homework and focusing on discussion and application of concepts in class (Bergman & Sams, 2012; Missildine, Fountain, Summers, & Gosselin, 2013). The Carnegie Foundation’s nursing education study supports significant innovation in prelicensure nursing education and recommends expansion of authentic pedagogies that focus on patient experiences, such as clinical simulation scenarios, unfolding case studies, and clinical conferences focused on reflection about student experiences (Benner et al., 2010). These recommendations call for significant changes not only in the structure and organization of the program of study but also the way the curriculum is delivered. As an example, Nielsen, Noone, Voss, and Mathews (2013) describe a model of clinical learning activities that take into consideration the developmental needs of the learner.

Nursing educators are being challenged to seize the opportunity and challenge of developing new programs of study for prelicensure students for the 21st century and beyond. The creative wisdom of nursing faculty, grounded in educational expertise and experience and in collaboration with practice partners, has 251the potential to shape a more effective, relevant, and responsive system of nursing education.

CURRICULUM DEVELOPMENT

The curriculum reflects the heart and soul of a nursing faculty. For each school, at least some of the current faculty were most likely involved in developing the existing curriculum and are invested in its success. The curriculum expresses the faculty’s values and beliefs about nursing and education, and reflects their professional identity. Faculty members have educated and mentored many students through the program and their courses have been the core of their daily work—in some cases, for many years. The curriculum is familiar and comforting. These factors mean that curriculum change is one of the most challenging undertakings for any faculty. It may prove difficult to build consensus about a new program based on different values and priorities among a diverse group of faculty members. Some faculty members have kept up with best practices and innovation in nursing education, while others are content with the status quo. Ideally curriculum revision is driven by the faculty and begins with an agreement by the faculty as a whole to enter into the process.

Once a decision has been made to revise an existing curriculum or develop a new curriculum, next steps include selecting a work group or committee, developing a plan, and exploring best practices in nursing education. The composition of the group that will be leading the work of developing the curriculum is of primary importance to the success of the endeavor, and the members should be selected with intention. A strong team includes a diverse group of tenured and untenured faculty with various areas of expertise and backgrounds that are committed to the goal, motivated to do the difficult work of curriculum development, and able to work collaboratively through the process of change (Mawn & Reece, 2000). In addition to faculty with passion for curriculum, a balanced group includes both faculty members with current practice experience and those with expertise by virtue of their long teaching careers. Nursing students bring a unique and practical perspective to the work and their participation enriches the curriculum development process. As the group organizes, a discussion about roles within the committee and ground rules facilitates the process. One strategy recommended by Hull, St. Romain, Alexander, Schaff, and Jones (2001) is for one member of the committee to assume the role of facilitator to make sure that the ground rules are followed and to mediate the inevitable conflicts. An early discussion of bias, territoriality concerns, and “sacred cows” contributes to the process. Other suggestions include a tentative plan and timeline to help the group to stay on schedule, and a plan for communicating the progress of the curriculum revision and points for feedback from the faculty as a whole.

The initial preparatory work of the curriculum development group is to review program evaluation data and plan a variety of strategies to identify best practices in nursing education. The extent of this effort will depend on the time elapsed since the last curriculum revision and the extent of the planned revision. The following information and documents will inform the committee and provide data for difficult discussions and decision making.

Information in this chapter is relevant to the development or revision of curricula for several types of baccalaureate programs that will be addressed, including 4-year traditional collegiate nursing programs, transfer programs in which students complete prerequisites and general education courses before entering the nursing program, accelerated (or fast-track) bachelor’s degree programs, and RN completion programs. If a school has more than one type of program, there must be consistency and congruency among programs. The suggested approach is to start with development of the generic prelicensure program and then develop modifications based on the core curriculum model. Examples of documents that describe the recent curriculum revision at Linfield-Good Samaritan School of Nursing (LGSSON) at Linfield College are presented throughout the chapter and supplemented by descriptions of innovations from other BSN programs.

The process of curriculum development is an iterative process of discovery, and the components of the curriculum package generally remain flexible until all parts are completed to allow for new insights and learning of the curriculum development team and the faculty. The curriculum development process begins with values clarification and development of a mission, vision, philosophy, and a specific 253goal or purpose of the program (as described in Chapter 9). These statements must be consistent with that of the parent institution and underlie all nursing programs at the school.

CONCEPTUAL FRAMEWORK

The conceptual framework (theoretical or organizational model) guides the development of the program of study and makes it unique; it unifies the curriculum and creates a coherent approach across courses and levels (Ervin, Bickes, & Schim, 2006). While there are some curricular elements that are common among schools based on the Essentials (AACN, 2008b), others define the particular identity of the program based on the characteristics of the parent institution and the philosophy of the nursing program. Traditional academic nursing frameworks no longer reflect the complexity of nursing education or practice. The use of a single theorist is an outdated approach and most nursing programs have an eclectic model that reflects their values and priorities (McEwen and Brown, 2002). The meta-paradigm for nursing that includes the key concepts of person, environment, health, and nursing is no longer an adequate foundation for an educational program (Webber, 2002). Theoretical models for BSN programs have shifted away from nursing process to critical thinking (McEwen & Brown, 2002) and reflect alternatives for the biomedical model that more closely reflect nursing concepts and values. If the theoretical model is basic and broad, it is possible for it to encompass and support a variety of views of practice and education that may be held by faculty (Ervin et al., 2006) and allow for new developments in nursing and health care (Newman, 2008).

The LGSSON Theoretical Model for Community-Based Nursing Education is grounded in the Baccalaureate Essentials and serves as an organizational structure for the curriculum. Figure 11.1 is a visual model of the LGSSON theoretical framework and reflects the school’s community-based philosophy. The outer circles provide context for the curriculum. The concepts of global community and social justice are a reflection of the mission statements of both the college and school of nursing. Health promotion, illness prevention, and treatment are not only a focus for global health, but priorities for local communities and health care reform. Within the school’s community of learning, the focus is on learner-centered education, which drives how students and faculty are engaged together on a journey of inquiry. The innermost circles of the model describe the content and approaches that structure the curriculum. Professional education reflects recommendations by the Carnegie Foundation for the Advancement of Teaching (Benner et al., 2010). The curricular themes of communication, community, diversity, ethics, health, and stewardship are foundational curricular concepts that are spiraled throughout the program of study and focus student outcomes. The modes of inquiry emphasize how the curricular themes and professional knowledge are acquired. For example, the faculty utilizes a clinical reasoning model that draws on evidence-based, reflective practice. Clinical praxis seminars are facilitated in such a way that reflective inquiry becomes a way of learning with the students. The liberal education circle again reflects the mission of the college and the school of nursing. This model was developed and approved by the faculty as a whole following extensive discussions.

254FIGURE 11.1 Linfield-Good Samaritan School of Nursing Theoretical Model for Community-Based Nursing Education.

The next step in the BSN curriculum development process is to identify level and terminal or end-of-program outcomes/student learning outcomes (or objectives or competencies), which must be directly related to the Essentials (AACN, 2008b) in the context of the school’s philosophy. Mapping is a strategy for ensuring that all elements of the Essentials (AACN) are included (see Chapter 9). Whether a school uses outcomes, objectives, or competencies to create the curricular structure, the term must be defined, used consistently, and leveled across the program. The outcomes form the backbone of the curriculum and will be the foundation for program evaluation. Student learning outcomes (end-of-program outcomes) can be developed by reviewing each essential and writing outcome statements that address the key concepts. This task can be completed either by the curriculum development group or be more inclusive and involve the faculty as a whole by assigning a small group of individuals to write outcomes for specific Essentials (AACN). When all outcome statements are reviewed and analyzed as a package, there will most likely be overlap and areas that need to be strengthened in preparing the final document. As the outcomes statements are combined and synthesized, some may address more than one essential, but all Essentials (AACN) must be addressed. When the terminal outcomes are identified, the level outcomes are developed and spiraled to show students’ progression through the program. Table 11.2 gives an example of curriculum outcomes as they relate to the Essentials (AACN).

255TABLE 11.2 MAPPING OF CURRICULUM OUTCOMES AND ESSENTIALS

There has been a resurgence in the use of competencies to structure curricula. Goudreau et al. (2009) identify the second-generation competency-based approach as grounded in a constructivist model that supports learning-centered approaches. Competencies are not constrained by the language of Bloom’s taxonomy but are statements of “complex know-hows” specific to the discipline that “allows one to deal with different situations by drawing on concepts, knowledge, information, procedures, and methods” (Goudreau et al., 2009, p. 3). For example, 256the 10 competencies developed by the Oregon Consortium for Nursing Education (OCNE) are not grounded in the behaviorist tradition but reflect the complexity and integration of empirical knowledge and practical knowing (Gubrud-Howe et al., 2003). The OCNE competency statements can be viewed at http://ocne.org/Curriculum%20Competency%20Approved%205-11-2012.pdf.

IDENTIFYING COURSES

In the next step, essential knowledge, skills, and attitudes that students will need to accomplish related to each outcome are identified. This is the content that is organized into coherent and logical groupings, which become courses. There are many possible ways to cluster the information and the faculty should be guided by their previous research and philosophical work. The identification of new courses can be an exciting and creative activity but has the potential to be a phase of the curriculum development process that creates conflict. Issues of territoriality and “sacred cows” may assert themselves; it is sometimes difficult to think creatively and safer to regress to what is known (the old model). At this juncture, decisions must be made about which concepts to integrate and which to organize into a separate course. In the creation of a working course template, a program of study by term begins to emerge. Table 11.3 shows the courses in the plan of study for the generic BSN curriculum at LGSSON.

TABLE 11.3 GENERIC BSN PROGRAM OF STUDY

The concept-based model for curriculum development is another way to reduce content saturation. In this approach, nursing faculty identifies, classifies, and defines concepts that subsequently provide the organizational framework for the curriculum and are threaded through courses (Giddens & Brady, 2007; Giddens, Wright, & Gray, 2012). For example, at LGSSON, the faculty identified six major themes that reflected the mission, vision, and philosophy of the school and were incorporated into the theoretical framework: communication, community, diversity, ethics, health, and stewardship. Essential concepts were identified for each of the themes and the concepts within each theme were spiraled from less to more complex and then leveled across four semesters. Although the emphasis on the themes varied from semester to semester and new information for each theme was introduced each semester, the expectation was that knowledge and skills were cumulative throughout the program. Examples of the leveling of the concepts within three of these themes are provided in Table 11.4.

TABLE 11.4 COMMUNITY-BASED CURRICULUM FRAMEWORK: CONCEPTUAL ORGANIZATION; EXAMPLARS OF CONCEPTS IDENTIFIED WITHIN CURRICULUM THEMES: COMMUNICATION, DIVERSITY, STEWARDSHIP (THREE OF SIX THEMES)

TABLE 11.5 ORGANIZATION OF CURRICULUM CONCEPTS INTO THEORY COURSES FOR THE FINAL TWO SEMESTERS

260Within each semester, concepts from all themes were organized into courses; as an example, the conceptual organization of the theory courses from the final two semesters of the program are shown in Table 11.5. By identifying more abstract concepts instead of content for each course, the faculty member is free to update and prioritize course content as it changes over time. For example, the concept of “environmental health,” which is introduced in semester 4, does not specify specific content and allows the teacher to vary explanatory models and exemplars according to current research and community priorities.

THE INCLUSIVE CURRICULUM: PAYING ATTENTION TO DIVERSITY

There is a national call to increase the enrollment of students from underrepresented populations in schools of nursing, and recent reports show that some progress is being made (Budden, Zhone, Moulton, & Cimiotti, 2013; U.S. Department of HHS, 2010). Learning-centered education generally addresses diverse learning styles and there is a growing body of literature regarding effective teaching and assessment strategies for nursing students from underrepresented populations (Bosher & Pharris, 2009). However, schools of nursing typically have not considered the needs of students who are minorities, low income students, first in family to attend college, or multilingual, nonnative-English speakers in developing the plan of study or the curriculum structure. Ideally, the curriculum should be creative, flexible, and reflect the multicultural perspectives of our pluralistic society (Warda, 2008). If diversity and cultural competence are part of the mission or philosophy of the school, related concepts should be included in the theoretical framework, made explicit in program and level outcomes, and reflected in concepts/content threaded throughout the curriculum (Crow, 1997). For example, at tribal colleges, curriculum is structured to focus on important elements of the Native American culture.

The American Association of Colleges and Universities (2014) promotes inclusive excellence, a commitment to diversity and equity based on the understanding that becoming an educated person in a pluralistic society includes developing the ability to communicate and interact with individuals and populations that are different from ourselves (Williams, Berger, & McClendon, 2005). This philosophy presupposes a broad definition of diversity, and compels faculty members to facilitate the success of all students, including those with diverse backgrounds and learning styles. Swaner and Brownell (2008) recommend high-impact strategies for the success of underrepresented minority students, including learning communities, service learning, undergraduate research, first-year seminars, and capstone projects that could readily be incorporated into the structure of nursing programs. Faculty may not be aware of how programmatic organization affects students differentially. For example, the practice of “front-loading” theory in a curriculum or a particular course prior to engagement in clinical practice disadvantages tactile and kinesthetic learners and this is the preferred learning style for many English as a second language (ESL) students (Reid, 1987). In a theory-first model, students who are having difficulty with theory miss the opportunity to reinforce classroom learning in the most effective way possible—through hands-on learning in the real world 261(Bosher, 2007). These learners would best achieve academically in a curriculum model that more closely integrated theory and clinical experience.

Other ways of demonstrating inclusiveness in curriculum planning include pre-entry nursing courses, parallel academic support courses, culture-focused or special interest general education courses or electives, and international experiences as part of the program of study. The co-curriculum can play an important role in supporting and validating underrepresented students on the campus. Other ideas include development of clinical models that facilitate clinical experiences with diverse populations and intentionally threading exemplars throughout the curriculum that address health care issues experienced by particular ethnic, cultural, or minority groups. Another strategy is to institute a curriculum requirement that ensures that students have a variety of experiences with populations or clients that are different from themselves. One promising practice in nursing education identified in a study of California nursing programs included organizing and scheduling the program of study to accommodate working students, which could include options for evening and/or part-time coursework (Buchbinder, 2007). And finally, admission and progression requirements for incoming students that support or, conversely, disadvantage those who were educated in another country or are multilingual nonnative English speakers will shape the student body and affect the quality of learning for all the students. A diverse student body has been shown to be associated with improved outcomes among all students (IOM, 2004).

INTERPROFESSIONAL EDUCATION: PREPARING FOR COLLABORATIVE PRACTICE

In response to quality and safety standards in health care and a vision for accessible, patient-centered care, AACN collaborated with leadership from other professional organizations to develop competencies for interprofessional practice (Interprofessional Education Collaborative Expert Panel, 2011), which have been integrated into the Baccalaureate Essentials (AACN, 2008b). The World Health Organization (2010, p. 7) stated that IPE “occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health.” Health professions schools are developing models for IPE in classroom, simulation, and, more recently, clinical and community settings.

IPE models have been studied in undergraduate nursing programs (Hudson, Sanders, & Pepper, 2013). The University of Florida requires an interdisciplinary family health course in which student teams make visits to volunteer families in the community, and the University of Washington developed the co-curricular SPARX program (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). Salfi, Solomon, Allen, Mohaupt, and Patterson (2012) described a framework for IPE in which students developed competencies throughout the curriculum beginning with learning about their own profession and culminating in their effective participation on the health care team. Shiyanbola, Lammers, Randall, and Richards (2012) implemented an IPE program with students from five health care profession programs, including nursing, that focused on care of an underserved diabetic population. At Oregon Health and Sciences University (OHSU), interprofessional student groups 262are working with a nursing faculty in residence and collaborating with community partners to address social determinants of health for some of the most vulnerable and marginalized clients, families, and populations in target neighborhoods. Details can be found at www.ohsu.edu/i-can.

Although there are significant logistical, cultural, and historical barriers to IPE and practice, the benefits of IPE for prelicensure students are many, including: greater understanding of roles and contributions of other health care professionals and dynamics within the health care team; development of professional pride and identity; importance of effective interprofessional communication and reflective practice; knowledge of patient conditions and increased comfort with targeted patient populations; improved cultural sensitivity; building of professional networks; and an improved sense of collaboration and cooperation (Angelini, 2011; Bridges et al., 2011; Buckley et al., 2012; Mellor, Cottrell, & Moran, 2013; Shiyanbola et al., 2012); Each school has unique opportunities and, going forward, IPE/interprofessional collaborative practice must be considered as an integral element of every baccalaureate curriculum.

TRANSFORMATIVE APPROACHES TO CLINICAL EDUCATION

One of the most challenging aspects of curriculum revision is designing an approach to students’ clinical experiences that reflects the school’s theoretical model and integrates new learning pedagogies in the context of local realities regarding the availability of qualified clinical faculty and clinical sites. While clinical experience is essential in preparation for practice, what constitutes clinical experience? What kinds of clinical learning activities and how much time in what kind of health care settings is most effective for BSN students to meet generalist competencies and transition successfully into practice? The National League for Nursing Think Tank on Transforming Clinical Nursing Education (2008) made recommendations for the ideal clinical education model that described integrative experiences, including cross-disciplinary experiences; new relationships within learning communities, including innovative relationships with clinical partners; and reconceptualized learning experiences in which all students don’t have clinical experiences in traditional rotations. While there are scarce data about the effectiveness of either traditional or new clinical models, it is incumbent on nurse educators to develop and test models and approaches and contribute to the database. Each school of nursing needs to develop an approach that best utilizes its resources and fits its theoretical model.

Clinical models: The traditional clinical education model in which a nursing faculty member provides direct supervision and oversight for a small group of students on a hospital unit is no longer practical or effective for several reasons:

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