Curriculum defined

Although there are a number of definitions that fit an epistemological approach to curriculum, Glatthorn, Bosche, and Whitehead’s (2006) definition of curriculum as “the plans made for guiding learning, usually represented in retrievable documents of several levels of generality” (p. 5) fits nicely with the notion of knowledge as a shared meaning. A major step in this planning is determining the desired learning outcomes that should occur as a result of this planning process. Therefore a pivotal question for faculty to ask is: “What should students know and do on completion of their educational experience?” Given today’s environment of accountability, the issue of functionality is paramount. The need for accountability permeates all aspects of education, from primary through postdoctoral educational programs. Therefore it is critical to appropriately determine what competencies—in terms of knowledge, skills, and attitudes—students must successfully demonstrate at the completion of a program that will meet the expectations of a dynamically changing health care system. Faculty must also decide what learning experiences will facilitate students’ attainment of these competencies and how the attainment of these competencies will be evaluated (Boland, 2004). Accountability requires that curricula remain dynamic, especially as education faces the challenges of what seems like an exponential growth in knowledge, the impact of technology on how we teach and students learn, and the evolving and uncertain future of the health industry (Forbes & Hickey, 2009).

The more contemporary or ontological definition of curriculum is determining the learning processes that “support students to develop confident and competent practice within the shifting, complex terrain of contemporary health care milieus” (Doane & Brown, 2011, p. 22). Knowledge becomes the background as curriculum is focused on engaging students in identifying, interpreting, and using knowledge as they become competent practitioners.

Curriculum frameworks as a building block

Curriculum frameworks provide faculty with a way of conceptualizing and organizing the knowledge, skills, values, and beliefs critical to the design of a coherent curriculum plan that facilitates student learning and their achievement of the desired educational outcomes. The value of curriculum frameworks is in their ability to provide the base for developing expected nursing competencies. Organizing or conceptual frameworks “allow students to apply what was learned to new situations and to learn related information more quickly” (Tanner, 2007, p. 52). This is critical, as the majority of nursing curricula today are overloaded, with students being overwhelmed by the amount of knowledge faculty expect them to entrust to memory.

Added to the complexity of curriculum development is the need to continue to address general education expectations and outcomes, which often are institutional specific. More and more emphasis is being placed on interdisciplinary learning and interprofessional collaboration and its impact on both undergraduate and graduate curricula. Today’s higher education environment is reemphasizing a strong general education foundation for all undergraduate and graduate students, and this orientation is having an impact on professional curricula that are already pinched for space and time. An example of this effort is noted in the “standards for success,” which were born out of a collaborative effort of the Association of American Universities and The Pew Charitable Trusts (2003). These standards tend to reflect lifelong learning skills that will continue to serve the learner as they move into a global workforce. These skills have been related to thinking critically, clearly expressing thoughts and ideas, clarifying their values, evaluating assumptions of self and others, and examining the evidence for thoughts and actions (Inderbitzin & Storrs, 2008).

The Institute of Medicine’s (IOM) Future of Nursing report recommendations clearly speak to the need for more interprofessional educational didactic and practice learning experiences (IOM, 2010). The report challenges schools of nursing to integrate these collaborative learning opportunities into the curriculum. Also, nursing faculty cannot ignore the need to incorporate personal and social values along with the economics of an educated workforce in the development of curricula. As these external forces continue to prescribe critical elements that need to be included, nursing must find ways to meet expectations without continuing to add to already overloaded curricula.

In determining what needs to be taught and learned within the context of the phenomenon of nursing, nursing itself must first be defined. The faculty’s philosophical beliefs about how teaching, learning, and the discipline of nursing should be viewed, described, and evaluated are often woven together into an organizing framework. This framework has historically guided the development of most nursing curricula (see Chapter 7). Organizing frameworks have been used in curriculum development to delineate the constructs embedded in a traditional philosophy statement that reflects the collective faculty belief. It is important that organizing frameworks not be construed as a permanent feature of a program but rather as a kaleidoscope of complex patterns related to what students need to know and how they will best learn it.

As faculty have moved away from developing formal philosophical statements, organizing frameworks have acted as a good substitute since they are conceptual in nature and reflect ideas and symbols inherent to the discipline of nursing. Their greatest utility is in providing faculty with a tool that turns mental images of nursing phenomena into visual schemes that represent the relationship of critical ideas and symbols to each other. This author would argue that this schematic conceptualization helps students understand the abstract nature of nursing. However, this conceptual level of abstraction has been a challenge for some students and faculty who view curriculum as a series of content units containing prescribed knowledge and technological skills that are to be taught. The focus on content blurs the essence of what nursing is.

Fawcett’s (1989) classic work on conceptual models and frameworks can provide readers with a discussion of theories, models, and concepts that is beyond the scope of this chapter. Organizing frameworks can be a means for creating access to knowledge about the phenomena of interest or importance to the discipline. Organizing frameworks do provide a logical structure for cataloguing and retrieving knowledge. This structure is essential to the processes of teaching and learning as faculty guide students in the development of cognitive linkages among knowledge to which they are exposed “which allows them to see patterns, relationships or discrepancies that are not apparent to novices” (Tanner, 2007, p. 52). Additionally, organizing frameworks can assist the learner in building a context for storing and retrieving nursing knowledge and helping to promote an understanding and application of knowledge to new or dynamic practice situations.

Purposes of organizing frameworks in curriculum development

The purpose in constructing frameworks is to systematically design a mental picture that is meaningful to the faculty and students when determining what knowledge is important and has value to nursing today and how that knowledge should be defined, categorized, and linked with other knowledge. Today’s critics of higher education are calling for the ability of graduates to be able to integrate knowledge and make application to complex and often uncertain situations. Ervin, Bickes, and Schim (2006) recognized that although the majority of nurses seek positions in acute care settings, there needs to be broader orientation to a continuum of care settings within a global context. This thinking is consistent with the recent IOM 2010 recommendation that tomorrow’s nurse be prepared to practice across a broad range of care settings. Organizing frameworks need to reflect both concepts relevant to populations and settings. In summary, organizing curriculum frameworks provide a blueprint for determining the scope of knowledge (i.e., which concepts are important to include in the teachers’ and learners’ mental picture) and a means of structuring that knowledge in a distinctive and meaningful way for faculty and students.

A number of approaches are used in defining and shaping frameworks. However, an organizing framework must reflect the sphere of nursing practice, the phenomena of concern to nurses, and how nurses relate to others who are dealing with health concerns (Bevis & Watson, 1989; Warda, 2008). Organizing curriculum frameworks are the educational road maps to teaching and learning. As with any road map, multiple route options are available for arriving at a given destination or outcome.

As faculty move toward the adoption of an outcome orientation in curriculum building, organizing frameworks or models will continue to serve the same purposes noted earlier but will be driven by philosophical views and futuristic mental pictures regarding the evolving practice of nursing. An example of an organizing framework that is shaping recent outcomes in baccalaureate curricula stems from the Quality and Safety Education for Nurses (QSEN) project. Using its recommendations that “graduate nurses must have the knowledge to describe strategies for learning about outcomes of care, the skill to use quality measures, and the attitude to appreciate quality improvement” (Forbes & Hickey, 2009, p. 5), faculty are able to identify outcomes of the learning process for their institution. As increasing attention is being given to student learning, the emphasis on curriculum is transforming from teaching to learning. With this paradigm shift comes the need to look at theories and frameworks focused on learning. The concepts of emotional intelligence (Dekker & Fischer, 2008; Fischer et al., 2005) and transformational learning (Mezirow, 1991; Taylor, 2008) are now being considered by faculty as they develop curriculum.

Developing an organizing framework for curriculum

It is not easy to decide on a specific organizing framework that will best serve a program. Faculty can use two traditional approaches in determining the kind of organizing framework they wish to construct. The first approach is to select a single, specific nursing theory or model on which to build the framework. The second approach is more eclectic: to select concepts from multiple theories or models. Both approaches are discussed further.

Developing a single-theory framework

One traditional approach to constructing an organizing framework is to use a particular nursing theory or model to help shape the visual image that is consistent with the philosophy of the faculty. For example, if faculty believe that “health encompasses conditions known as disease and that it is an expansion of a person’s consciousness” (Newman, 1997, p. 22), faculty will probably adopt Newman’s theory of health as the vehicle for organizing knowledge for that particular nursing program. However, if faculty believe that caring is at the core of nursing, Watson’s (1997) theory of caring might better serve when explaining the discipline to students and cataloguing knowledge about the discipline of nursing.

The advantage to building an organizing framework on a single theory or model is the ability to use a single image with a defined vocabulary that is shared by both the learner and the teacher. Drawing further on Watson’s theory as an example, she says that “the transpersonal caring relationship and authentic presencing translate into ontological caring competencies of the nurse, which intersect with technological medical competencies” (Watson, 1997, p. 50). The image put forth in this description is “transpersonal caring relationship,” which is at the core of Watson’s theory. “Ontological caring competencies” and “technological medical competencies” evolve from this caring relationship. It is the development of these competencies that students would be expected to demonstrate in a program in which Watson’s theory guided the knowledge to be learned and determined the expected performances of the program’s graduates.

Using a single theory or existing conceptual model has limitations and poses challenges. One theory or model may not reflect everybody’s visual image or view of nursing and nursing practice. This becomes problematic when faculty have developed or been educated in curricula that have used a different theory or orientation to the discipline (Webber, 2002). Forbes and Hickey (2009) suggest that the use of only one theory in a framework limits the ability of faculty to pull together all elements of their curriculum, which provides a rationale for moving away from this approach.

One of the more common challenges in using a theory is being able to take an ethereal explanation of reality and make it understandable for students being newly introduced to the discipline. The language of a theory also can pose challenges for faculty and students. Especially for beginning nursing students, the language of the theory and the definitions of the critical concepts may be too abstract to be helpful in promoting shared understanding and a common vision for learners and teachers. A good theory must also stand the test of time. Theories must continually be tested to determine relevance with current reality. As the practice of nursing is being transformed by a dynamic, evolving health care system, it is imperative to determine the degree to which any single theory is useful or practical. It is clear that nursing educators and practitioners will not, at least in the foreseeable future, agree on a single theory. Students educated in a curriculum driven by a single theory are likely to experience frustration and confusion when they find themselves in clinical practice settings that do not ascribe to the same theory, or to any theory for that matter.

Developing an eclectic framework

Given the challenges and limitations of using a single theory as an organizing framework, faculty choice does not have to be constrained by a single theory or model. Those who believe that a combination of many theories or concepts is more reflective of their beliefs about nursing may use an eclectic approach to developing a curricular framework. For example, an eclectic framework might include the concept of nursing as defined by Florence Nightingale, the concept of needs as defined by Maslow, the concept of self-care as defined by Orem, and the concept of a caring relationship as defined by Watson (Fawcett, 2000). All are critical concepts, but each concept comes from a different theory or theoretical orientation.

The use of a more eclectic approach when designing an organizing framework is not without its pitfalls. Some view this approach as an impediment to the development of a comprehensive nursing theory and the development of a body of knowledge that is uniquely nursing. The advantage to an eclectic approach is the ability to “borrow” concepts and definitions that best fit the faculty’s beliefs and values from nursing and nonnursing theories. However, if faculty develop an eclectic framework, where concepts and their definitions are “borrowed” from a number of theories, they need to ensure that in the act of borrowing they have not changed conceptual meaning. It is important to retain the original definitions and the characteristics or attributes used to explain or validate the existence of borrowed concepts in altered contexts.

For example, the concept of hope may be perceived as critical to the understanding of how individuals make decisions about self-care. If a person has hope that a certain self-care action will have positive results, he or she is more likely to perform that self-care behavior. A person without hope is less likely to initiate that self-care behavior. If a market analyst were to use the concept of hope in a model to predict sales trends, that analyst must determine whether hope has meaning that is altered by, or separate from, the current context in which it will be used. Borrowing concepts from other disciplines is acceptable as long as those doing the borrowing are cognizant of how, in the act of borrowing, the concept may have changed some of its characteristics. Therefore it is important to clarify the meaning of concepts that will be used in an organizing framework so that faculty and students are clear about the phenomena being studied.

Examples of nontraditional curricular frameworks

Historically, accreditation standards and performance expectations have had a significant impact on many organizing frameworks as faculty have moved to incorporate or add into their organizing frameworks and curriculum models such concepts as critical thinking, problem solving, communication, caring, diversity, and therapeutic nursing interventions (McEwen & Brown, 2002). Although these concepts can be compatible with the essence of nursing, they are often not defined well enough to be consistently used by the teacher or applied by the learner. Faculty adopting an outcome orientation to curriculum must be able to construct the context and meaning that these outcomes will have in the curriculum structure. Critical thinking is one outcome that most undergraduate programs have adopted. A number of nationally normative tools have been created to measure critical thinking both on entry into and exit from a program. However, critical thinking as a cornerstone of an organizing curriculum framework is often not well defined, nor are its attributes identified for systematic and purposeful incorporation into nursing curriculum or assessment activities. Critical thinking is a skill, and without a nursing-oriented context to ground this skill, it is meaningless in and of itself. If the means is critical thinking, then faculty must determine the end in the development of the context. It is interesting to note that accreditation standards are moving away from prescribing expectations almost as quickly as these expectations were first embraced.

As faculty move away from the more traditional use of theory or theories in designing curriculum frameworks, a number of unique designs have been identified. One interesting approach to an eclectic curriculum design is the KSVME framework (Webber, 2002). This framework is constructed around five “conceptual cornerstones”—nursing knowledge, nursing skills, nursing values, nursing meanings, and nursing experience (Webber, 2002, p. 17)—and incorporates many of the recognized concepts present in today’s nursing curricula.

The healing web is another example of a collaborative effort to design an organizing framework whose conceptual orientation is woven into a “collaborative clinical practice in a differentiated practice model” (Nelson, Howell, Larson, & Karpiuk, 2001, p. 404). The healing web draws components from Newman’s health theory and Watson’s caring theory to construct the essential building blocks of this “transformative model” (Nelson et al., 2001).

The emancipatory curriculum, designed to focus less on structure and content and more on the dynamic of learning through discovery, dialogue, and critical reflection, is yet another approach to creating a more meaningful educational experience (Diekelmann, Ironside, & Gunn, 2005; Schreiber & Banister, 2002). Although this curriculum design was conceived as the antithesis of the traditional structured curriculum designs, it is still anchored in philosophical conceptualizations from phenomenology, feminist theory, and critical social theory (Schreiber & Banister, 2002, p. 41). Challenges to a more individualized approach to curriculum structure can vary depending on individual faculty beliefs, experiences, and priorities.

The Quality and Safety Education in Nursing: Enhancing Faculty Capacity has developed a quality and safety framework that is being used to revise or is being incorporated into existing curriculum frameworks. This work began in 2005 through Robert Wood Johnson Foundation funding and the American Association of Colleges of Nursing (AACN) holding regional meetings designed to facilitate the incorporation of this framework into prelicensure programs (AACN, 2010). The Oregon Consortium for Nursing Education (OCNE) model is gaining in popularity across the country and has a number of elements believed to address some of the challenges in nursing education today (OCNE, 2006).

These eclectic approaches to thinking about curriculum frameworks appear to be driven by the need to make the education of nursing students relevant to tomorrow’s practice of nursing. Relevancy is being defined around such concepts as differentiated practice, evidence-based practice, and care outcomes. As faculty and practitioners of nursing struggle to reenvision nursing practice for the next century, these concepts will assume center stage in the various curriculum dialogues. It is crucial that practice and education recognize and assume active roles in all future curriculum development activities. Without shared understanding and common goals there is little to ensure the relevancy of graduates beyond the skills they will develop in their educational programs. Although it is essential to build an undergraduate curriculum around the science of nursing, it is imperative to maintain the science of nursing knowledge in graduate programs, especially as faculty are reexamining graduate education with the doctorate in nursing practice (DNP) often replacing existing master’s programs. Without a substantial and sustained commitment to the science of nursing, the practice of nursing will soon lose the guidance that frameworks offer.

Designing a graphic of the framework

Although it is unnecessary to accompany the description of the organizing framework with a graphic or model, it can be helpful for those trying to grasp concepts or ideas enfolded within the framework. A graphic can provide clarification, especially when the framework is complex or abstract. Simply put, the graphic facilitates how to see the association among concepts for the visual learner.

When developing organizing frameworks, faculty should be guided by a “less is better” approach. Faculty should remember that curriculum-organizing frameworks are roads to a specified destination, not the trip itself. If the framework is too complex, students and faculty spend more time trying to interpret and understand the framework than they do actually implementing and evaluating it. This trade-off is devastating because time is often perceived as the rarest of commodities in today’s undergraduate and graduate nursing programs.

An example of a simplistic curriculum structure may include the concepts of health, person, and environment. As shown in Figure 9-1, if health has been defined as a continuum, with wellness at one end and illness at the other, the mental picture is very simple.

Adding the concept of person to this model requires that person first be defined. If a person is believed to have the ability to balance wellness and illness to achieve a high level of wellness, an additional dimension could be added to the model as depicted in Figure 9-2.

When the concept of environment is incorporated into the image, it creates additional complexity. If we define the environment as an external force that affects a person’s ability to balance his or her state of wellness along the health continuum, shown in Figure 9-3, person and health occur within the context of an open environment, and the environment that is wrapped around the person affects the person’s ability to balance his or her wellness state.

These examples demonstrate how busy a framework can become when concepts are added.

Again, with increasing emphasis on learning it is critical that the learner and learning become visible in curricular models or conceptual maps. As nurse educators we have spent the majority of our time attending to issues surrounding discipline-related knowledge. Today our lens must include the process by which learners are motivated to learn, how they construct what they are learning, and how they transport that learning into meaningful thoughts and actions (Taylor, Fischer, & Taylor, 2009).

Clancy, Effken, and Pesut (2008) describe complex systems as being constructed from a “highly connected network of entities from which higher order behavior emerges” that they believe has significant implications on how we think about learning and the practice of nursing (p. 249). The assumptions growing out of the work related to complex systems support the need to focus on learning and the integration of the student both in the knowledge being taught and in the process in which the knowledge is learned and used.

Summary

However faculty decide to approach the work of developing a framework for their curriculum, the framework eventually constructed must be consistent with the school’s mission and philosophy statements, faculty values and beliefs, program goals, professional standards, state and federal regulations, and current and future nursing practice trends. Faculty should have broad-based agreement on the curriculum framework because such agreement is fundamental to the consistent interpretation, implementation, and evaluation of the curriculum in meeting the expected program goals and outcomes. This aspect of curriculum development can be time-consuming and is currently under some scrutiny within the profession because of the time associated with the process. It is critical to develop a framework that will prepare students to function in a dynamic and complex practice environment. If there is a disconnect among philosophy, values, program expectations, professional practice expectations and outcomes, and the framework, faculty need to raise significant questions as to the utility of the created framework.

Guiding principles for developing a curriculum framework

Although there are no specific steps or “how to’s” for developing organizing frameworks for curriculum, there are some guiding principles to follow. The first principle is to choose those concepts that most accurately reflect the faculty’s beliefs about the practice and discipline of nursing and how students learn. More contemporary approaches to learning, which stem from constructivism theory, are consistent with students and their learning being at the forefront of curriculum development. The concepts identified should also reflect or complement the philosophy, mission, and goals of the college or university in which the program is embedded. By creating an organizing framework that reflects concepts valued by both the discipline of nursing and the parent institution, faculty have begun to articulate the contributions their nursing program makes to all stakeholder entities. Mission statements, goals, or expected outcomes are the starting point for choosing concepts for inclusion in the curriculum framework. As higher education institutions focus on learning, it is important to incorporate the expression of this mission and goal as well.

Most traditional undergraduate curriculum frameworks minimally contain the concepts of health, person, environment, and nursing as they attempt to identify the essence of nursing. These four concepts, first collectively discussed by Florence Nightingale (1969), are still considered cornerstones of many nursing theoretical models even though they are defined differently by different theorists. Many philosophy and mission statements of schools of nursing still speak to these concepts from their own unique perspective. Faculty often expand their mission and philosophy statements to include such additional concepts as caring, self-care, diversity, growth and development, nursing process, adaptation, informatics, and evidence-based practice. However, there is no edict that faculty must follow when determining the concepts or configuration of concepts that will form the framework for the curriculum.

As noted earlier, some of the newer curriculum models have focused on nursing practice–related concepts and less on nursing discipline–related concepts. What is important in defining the concepts that tie the curriculum together is relevancy. This means that the concepts you choose need to be relevant to the future practicing nurse and consistent with the science of nursing. Again, it is critical to reach out to clinical partners or those hiring your graduates to help identify what is and will be relevant for tomorrow’s practicing nurse. It is also important that the needs and desires of the students be taken into consideration, especially as their learning becomes a major focus. Requisite knowledge and competencies are categorized around what nurses do with knowledge gained through their education rather than on what nursing is. This refocusing will continue to be prevalent in the minds of both practitioners and educators of nursing who are being asked to articulate nursing’s unique contributions to the health care and education systems in which nurses learn and work.

An updated view of a nursing framework can be seen in the complex adaptive system model proposed by Chaffee and McNeill (2007). For graduate education, the Nurse Educator Pathway Project is an example of competencies that faculty identified from their nurse educator program. These competencies are the “ability to demonstrate knowledge of and engagement with educational theories; fosters effective teaching and learning relationships; facilitates learning and creates effective learning environments; understands and works with multiple complexities related to learning; advances nursing professional practice; and demonstrates leadership abilities” (Young et al., 2010, p. 6).

The second principle is to clearly define these concepts. Consensus should be established in this process because it will fall to the faculty to articulate these concepts to the students. Concepts that are too obtusely, concretely, or narrowly defined are problematic, especially for undergraduate curricula that typically have espoused a “generalist” conception of nursing practice. If faculty wish to adopt a specific theory or theoretical orientation that they find congruent with their mission and philosophy, the concepts and definitions are derived directly from the theory or theoretical model. If faculty select a more open or eclectic approach, the definition of these concepts should reflect back to the philosophy, mission statement, or discipline in which the concepts were originally conceived.

There appears to be a rebirth of the integrative curriculum that gained popularity in the 1960s and 1970s. An integrative curriculum is designed to integrate knowledge from more than one discipline (Spelt, Biemans, Tobi, Luning, & Mulder, 2009). This curriculum approach focused on concepts perceived as critical to the practice of nursing. They often were drawn from a variety of theories or theoretical models and provided the foundation on which the curriculum was constructed. Today there is growing interest in core concepts as a focal point of curriculum construction (Giddens & Brady, 2007). The transformative curriculum is also gaining in popularity as more and more faculty are investing in learning. A transformative curriculum is based on the idea of students having a big-picture view of what they are learning (connective reality), having the opportunity to interact with the knowledge in a critical and reflective way (engagement), and being encouraged to construct meaning and actions appropriate to their learning (command of information). An example that supports the ideas of transformative curricula is embedded in the “learning centered curricula” proposed by Candela, Dalley, and Benzel-Lindley (2006), in which student learning becomes the focal point of the curriculum.

The third principle to attend to in this development process is to explain the linkages between and among the concepts identified. This is critical because the linkages are the basis for how students comprehend, apply, analyze, synthesize, and evaluate knowledge learned throughout the educational process. These principles are analogous to putting together a jigsaw puzzle in which the concepts are the puzzle pieces. Puzzles come in various numbers of pieces. Usually the greater the number of pieces a puzzle has, the greater the challenge in its construction. The outline and coloring of the pieces are the definitions of the concepts. The more clearly the puzzle pieces are defined and the sharper the color delineations, the easier it is to fit the puzzle together. The linkages between the concepts can be related to the coupling of the puzzle pieces themselves into a picture that reflects a mental image that will be easily recognized. It is the picture puzzle that is emphasized in higher-order thinking that we wish students to be able to demonstrate at program completion.

Recognition of patterns is a critical outcome that one hopes faculty can achieve in the development of curriculum frameworks and students can obtain as they move through the program. The resulting framework or model must present a “gestalt” of the nursing theory or models from which the concepts are taken. It is critical that faculty and students grasp an understanding of the framework without an intensive investment of time and energy. Csokasy (2002) suggests that “to maintain curriculum integrity, it is critical that faculty design all curricular activities to reflect the selected philosophical framework” (p. 33). The cornerstones of all frameworks must be reviewed on a regular basis to ensure continued relevance to the education and practice of nurses. Lindeman (2000) suggests that “nurse educators must prepare nurses for the emerging health care system and not the system of the past or one that they wish were in place” (p. 7). This is truer today than ever as health care systems are operating in an uncertain, ambiguous, and changing environment. The National League for Nursing Education Advisory Council Competency Work Group (2010) has developed an integrated curriculum model that speaks to what is perceived as changes in education to complement the changes in a dynamic health care system.