185CHAPTER 9

The Components of the Curriculum

Sarah B. Keating

OBJECTIVES

Upon completion of Chapter 9, the reader will be able to:

OVERVIEW

Chapter 9 provides an overview of types of educational institutions in higher education and how the various levels of nursing education fit into them. It continues with a discussion about the classic components of the curriculum, which include:

This chapter provides a sample nursing curriculum developed from the fictional case study in Chapters 6 and 7, the needs assessment. Table 9.1 provides guidelines for assessing the key components of a curriculum or educational program. Chapters 10 through 15 discuss in detail levels of nursing education from the associate degree through the PhD with Chapter 14 applying the components of the curriculum to staff development and health education. Chapter 20 responds to the issues that arise from the myriad levels the nursing education for entry into practice and proposes a plan that promotes a unified approach to nursing education for the readers’ consideration and debate.

TYPES OF INSTITUTIONS

Types of higher educational institutions are classified as private and public, and undergraduate or graduate. The types of nursing education programs addressed in this text range from the associate degree to the doctorate level. Many nursing curricula include step-in and step-out educational programs that provide career ladder opportunities for nurses. Most institutions of higher education identify themselves according to classifications found in the Carnegie Foundation for Advancement of Teaching Classification (2014). The Carnegie classification was first published in 1970 with the most recent classification occurring in 2010. The 2010 designations are according to what institutions teach (undergraduate and graduate programs), whom they teach (student profiles), and the size and setting of the institution. The basic classifications include:

A listing with a detailed description of each type of classification is available at http://classifications.carnegiefoundation.org/descriptions/index.php.

187For the purposes of this text, the discussion about types of higher education institutions includes private (nonprofit and for-profit) and public institutions (federal, state, or regionally supported) as well as community colleges, small liberal arts colleges, large multipurpose or comprehensive colleges and universities, research-focused universities, and academic health science/medical centers.

Sectarian and nonsectarian institutions are yet another classification with sectarian institutions reflecting a religious affiliation, for example, Catholic University, Southwest Baptist University, Brigham Young, and so on. While curriculum development activities are quite the same across types of institutions, the differences arise when examining the overall purpose of the institution and the financial and human resources that are available for revising or initiating new programs.

LEVELS OF NURSING EDUCATION

The levels of nursing education discussed in this text include associate degree programs that are usually housed in community colleges. These colleges are regional, public-supported institutions; however, there are some privately funded 2-year colleges that include nursing programs. Baccalaureate, master’s, and doctorate nursing programs are found in both state-supported and privately funded institutions. There are a few “single-purpose,” nursing-only schools. Many of these schools are or were former diploma, hospital-based programs with the latter converting to associate degree or baccalaureates in nursing. There are relatively few diploma program left owing to the financial constraints they face as well as the need for providings the liberal education and basic sciences that undergird nursing programs. Most hospital-based diploma programs are affiliated with higher degree programs, for example, community colleges and baccalaureate and higher degree programs. According to the American Association of Colleges of Nursing (AACN) Nursing Fact Sheet (2014d), diploma programs account for roughly 10% of all nursing programs in the United States. VickyRN (2014) reports that most of the remaining diploma schools are located in the east and midwest United States.

For all types of programs, administrators and faculty should plan in advance for financial support of curriculum development and evaluation activities and investigate possible external resources for support such as grants for curriculum changes and program development activities. A program that has been available over the years for nursing program development or expansion is the Health Resources and Service Administration’s (HRSA) division of nursing programs that include Advanced Education Nursing Traineeship (AENT), Advanced Nursing Education (ANE), Advanced Nursing Education Expansion (ANEE), Innovative Nurse Education Technologies (INET), Nurse Anesthetist Traineeship (NAT), Nurse Education, Practice, Quality, and Retention (NEPQR), Nurse Faculty Loan Program (NFLP), Nurse Managed Health Clinics (NMHC), Nursing Assistant and Home Health Aide (NAHHA), Nursing Workforce Diversity (NWD), and Personal Home Care Aide State Training (PHCAST) (U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Professions, 2014). See Chapter 8 for a discussion on financial support for curriculum development.

188THE FORMAL AND INFORMAL CURRICULA

The formal curriculum is the planned program of studies for an academic degree or discipline. It includes the components of the curriculum that are discussed in this chapter and the curriculum plan is visible to the public through its publication in catalogs, recruitment materials, and on websites. The informal curriculum is sometimes termed the hidden curriculum, or co-curriculum, or is composed of extracurricular activities. These planned and unplanned influences on students’ learning should be kept in mind as faculty assesses and develops the curriculum. Examples include special convocations with invited speakers, student organization activities that parallel course work, and outside-of-class meetings with students and faculty to enrich learning experiences. The co-curriculum incorporates planned activities such as collaboration with other academic units, student affairs meetings (information meetings, orientation, counseling sessions, etc.), field trips, work–study programs, service learning, and planned volunteer services in the community. Examples of extracurricular activities are athletics, social gatherings, and student organization events.

Some examples of the informal curriculum’s influence in nursing are student services activities and counseling, special convocations, graduations, honor society meetings, study groups, student nursing association meetings, student invited attendance at faculty meetings, participation in academic committees, and so on. Many schools of nursing schedule informal student–faculty meetings, holiday parties, and special events such as pinning ceremonies, honors convocation, and so on. These activities provide opportunities for student–faculty interchanges to enrich and supplement the formal classroom setting as well as facilitate leadership opportunities for the students.

Effects of Student–Faculty Interactions on the Curriculum

Student–faculty relationships are important factors to consider and influence the unplanned curriculum. Micari and Pazos (2012) studied student and faculty interactions in organic chemistry classes and the influence that the interactions had on students’ performance and perceptions about the course. They found that students’ grades and confidence in the courses were positively correlated with their interactions with faculty. They offer useful suggestions for faculty on how to connect to students to foster a positive learning experience.

THE CAMPUS ENVIRONMENT

The physical environment for the delivery of the educational program is important to the image of the home institution and plays a major role in building a sense of belonging for students and alumni alike. Broussard (2009) talks about the influence of the architecture and landscape of the home campus that creates lasting relationships among students, alumni, faculty, staff, and the community. He talks about “transformational places” on campus where the college community has time to congregate and share ideas and experiences. He makes a point about commuter 189students and the need for campuses to build into the landscape places where they too can experience a feeling of community.

Elkins, Forrester, and Scott (2011) conducted a study of students’ perceptions of the college campus sense of community according to how they were involved in campus activities other than those associated with formal learning. Using factors identified in the literature and adjusting them to their campus, they found that the sense of community differed according to the types and extent of students’ extracurricular activities. Additionally, they found that the more students were involved, the more they gained knowledge of the history and traditions of the institution and this gained sense of community contributed positively to student learning.

Fuggazato (2009) describes the close ties of the institution’s mission to its physical facilities. The mission can serve to structure buildings and rooms to enact its mission, for example, a student activities center that provides opportunities for student governance and participatory citizenship. He describes how institutions can evaluate their effectiveness by examining the mission and how physical structures on campus serve to realize elements of the mission.

While the physical environment plays a small role in programs that are delivered in cyberspace, some colleges and universities require periodic on-campus academic program meetings or residencies and special events for distance education students to experience the on-site campus. Another strategy is to provide program information materials that include pictures of the campus and campus life. This helps students to identify with the physical location and landscape to form images unique to the home campus. Other strategies for delivering the informal curriculum and an academic environment online include virtual faculty office hours and student and faculty meeting rooms.

Greener (2010) conducted a qualitative study (detailed grounded analysis of interviews of faculty) to discover their perceptions about the virtual learning environment (VLE) for courses taught online. The author introduces the notion of plasticity in the online learning environment, for example, adapting to the learning styles of students and learning activities according to the subject and different student needs. This is in contrast to the in-person, structured classroom environment. The VLE offers challenges for teachers to develop learning strategies and the opportunity to become more interactive with the student in order to meet learner needs. Building in activities that connect the online learner to the physical campus contributes to the students’ sense of belonging and community. On-campus orientation meetings, defense of scholarly works, and graduation activities can serve to connect the online learner to the campus.

COMPONENTS OF THE CURRICULUM

The following discussion examines each of the major components of the curriculum from the vision or mission statements to the philosophy statement that embraces faculty beliefs and values about teaching and learning; critical thinking; liberal education and the sciences; the health care system, organization, policy, finance, and regulation; clinical prevention and population health; interprofessional collaboration; professionalism, professional values, and nursing practice; social justice and 190advocacy; scholarship, research, translational science, and evidence-based practice; information systems and technology; and quality health care and patient safety. A description follows on how the organizational framework, overall goal or purpose, SLOs (end-of-program objectives), and level objectives constitute the implementation plan that flows from the mission and philosophy statements.

THE MISSION OR VISION STATEMENT

Traditionally, higher education institutions in the United States have three major elements included in their mission, that is, teaching/learning, service, and scholarship/research. The mission statement for each institution depends upon the nature of the institution and the three major elements are often divided into separate permutations. In more recent times, some organizations either replace or supplement the mission statement with a vision statement. For the purposes of this discussion, the mission statement is the institution’s beliefs about its role and responsibilities for the preparation of its graduates (outcomes). It may discuss the classic teaching/learning, service, and scholarship functions as they relate to the purpose of the institution. A vision statement is outlook oriented and reflects the institution’s plans and dreams about its direction for the future. It is usually short, visionary, and inspirational.

Meacham (2008) conducted an analysis of mission statements in higher education. He studied over 300 missions of universities identified by The Princeton Review (2001) as the 331 best colleges across the United States. Findings were similar to those of Morphew and Hartley (2006) with most missions emphasizing liberal arts, service, and social responsibility. Meacham discusses the utility of mission statements for orientation of new faculty and administrators to the history and purpose of the institution, assessment of the program and its relevance to current goals, utilization for campus-wide discussions on current issues confronting the institution, and visualization of the future direction of the university/college.

Colder (2011) surveyed Canadian higher education institutions’ website mission and vision statements. He found that 81% (n = 65) of the institutions went through a planning process to develop the statements. He states that while a mission should focus on the outcomes or purpose of the institution in order to provide direction for its members, many spoke of learning processes and the means to achieve the outcomes rather than the outcome. Regarding vision statements, Colder found that many institutions described their current state, rather than the future and many were lengthy rather than the brief, short, to-the-point visions for the future.

Chief administrators (presidents) of institutions of higher learning assume much of the responsibility for assuring that the mission and vision are current and reflect the purpose of the college or university. They provide the leadership and resources for administrators, staff, faculty, and students to implement the mission and vision, to maintain its relevancy in the community, and to meet future education needs. Developing or revising mission and vision statements are usually a part of a strategic planning process that involves all of the constituents within the institution.

191The purpose/mission of the institution is examined and a vision statement is developed that looks into the future for the next decade or two. These activities foster creativity and a movement toward the future that provide the framework for planning. After consensus is reached, the mission and vision statements serve as the guiding documents for developing long-range goals and implementing them. Another consideration related to the mission is the congruence of the statement with its actual implementation. Measures to determine if the mission is realized throughout the educational process and according to the expectations of graduates’ performance in the real world, give feedback as to how well the mission is met. For example, if the mission has a strong research emphasis, there should be adequate support and funding for faculty to write grants to sponsor research, and released time and facilities to conduct their studies.

Another aspect to the implementation of the mission is a cost analysis of the budget to relate the amount of monies allocated to the various functions of the program that support the mission. Academic and infrastructure support systems are analyzed for congruency with the mission. An example from nursing is an institution’s support and commitment to a nurse-managed primary care clinic that serves the underserved and unserved populations of the community in which the institution is located. In this example, the clinic meets the institution’s mission to serve the community.

Unless the school or department of nursing is a stand-alone academic entity, the mission of the major academic division, for example, college or school, in which it resides, is examined in addition to that of the parent institution. Both the missions of the parent institution and its academic subdivision should be congruent with each other and provide guidelines for the mission statement of the nursing program. These statements depend upon the nature of the institution and the nursing program. Smaller institutions may focus on liberal arts as a basis for all disciplines and professional programs to meet societal needs, while large research-oriented universities or academic health sciences centers might espouse new knowledge breakthroughs by its faculty’s and graduate students’ research. In the case of the former, nursing’s mission statement would reflect the graduation of well-prepared nurses to meet current and future health care demands; the latter would have an emphasis on nursing research and leadership in the profession.

As with the presidents of universities and colleges, deans and directors of nursing education programs have a leadership role in developing program missions and visions that are not only congruent with the parent institutions, but look to the future. Additionally, the mission needs to be examined frequently for its relevance to the rapidly changing health care system and the needs of society.

PHILOSOPHY

A definition for philosophy is listed in Merriam-Webster (2014) as a “critical examination of the rational grounds of our most fundamental beliefs and logical analysis of the basic concepts employed in the expression of such beliefs.” The philosophy for a curriculum should flow from the mission and vision. It gives faculty members the opportunity to discuss their beliefs, values, and attitudes about nursing and an 192education that imparts a body of knowledge and skills for the next generation of care providers. Faculty members discuss their beliefs about their specific school of nursing and its role in preparing nurses for the future, including statements on teaching and learning theories, the development of critical thinking, and beliefs about the essentials of nursing education including liberal education and the sciences; the health care system, organization, policy, finance, and regulation; clinical prevention and population health; diversity; interprofessional collaboration; professionalism, professional values, and nursing practice; social justice and advocacy; scholarship, research, translational science, and evidence-based practice; information systems and patient care technology; and quality health care and patient safety. Each individual member holds his or her own personal philosophy of education and nursing and thus the development of a philosophical statement can become an arduous task to agree on. Nevertheless, the resulting statement reflects the faculty’s (as an entity) rationale for the school of nursing’s existence and it serves to flavor the remainder of the curriculum components, their implementation, and their outcomes.

The first task in the development of a philosophy statement is to look at those of the parent institution and the subdivision of the parent in which nursing is housed. The ideal nursing philosophy incorporates all of the components of the other two philosophies, although at times there are mismatches to some of the specific components. In those instances, a rationale as to why that incongruence exists and how the nursing program meets other components of the philosophy should be discussed. Eventually, this rationale is documented so that members of the school and external reviewers understand the fit of the nursing program within its parent institution and subdivision.

Some examples of incongruence of a nursing program’s philosophy with its parent institution’s philosophy occur when the program is within a traditional, liberal arts college that has no other professional programs. In this case, the nursing program’s philosophy speaks to the importance of a strong liberal arts foundation for its graduates and the role of the nursing program to produce graduates who provide health care for the community. Another example is a nursing program housed within a school of engineering, along with several other professional programs such as computer science and journalism. In this case, nursing emphasizes the professional education aspects and preparation of professionals who serve the community.

The majority of nursing education programs’ philosophies include basic theories, concepts, beliefs, and values of faculty. The statement can be brief and succinct or lengthy; however, it should offer guiding principles for the remainder of the curriculum and should be evident in the organizational framework(s), goals, objectives, and implementation plan. The following discussion reviews many of the concepts found in nursing education program philosophies and is offered as a way for faculty to share ideas and beliefs and find consensus for developing or revising the program’s philosophy.

BELIEFS ABOUT TEACHING AND LEARNING PROCESSES

Beliefs about teaching and learning form the premise for the delivery of the nursing curriculum. In the past, courses were traditionally delivered through classroom 193lecture, clinical laboratory sessions, and clinical experiences in the reality setting. The emphasis was on teaching and the curriculum reflected that modality. In the more recent past, with the focus on program outcomes and the advent of technology, the emphasis changed to learner-centered education. The role of the teacher, instead of transmitter of knowledge, became a role of expert, mentor, and coach. Teaching strategies fostered student participation in learning activities instead of acting as passive receivers of knowledge. With the change in focus to the learner, theories and principles of teaching and learning served as guides for assessing the characteristics of the learners and adapting those theories and principles to the needs of the learner. Chapter 4 of this text reviews learning theories applicable to nursing education.

Cox, McIntosh, Reason, and Terenzini (2011) investigated what factors influence a “culture of teaching” in institutions of higher learning. They surveyed 45 colleges and universities representing liberal arts, comprehensive, and research institutions with 5,512 usable faculty members’ responses. They found that the major influence on faculty’s perceptions of the institution’s “culture of teaching” focus was dependent upon the type of institution and not its policies. The public and academe continue to value research institutions and place faculty’s research productivity above teaching activities. The authors conclude that in spite of the findings that academic policies have little influence on building a learner-centered environment, there remains a need to develop a culture and environment in all institutions that place emphases on learner-centered teaching and SLOs.

CRITICAL THINKING AND ITS APPLICATION TO NURSING

Chapter 5 of this text discusses educational taxonomies and strategies for developing critical thinking that give faculty members ideas on how these theories and concepts apply to their specific nursing program. The resultant sharing and discussions are summarized and become part of the philosophy statement. Development of critical thinking is essential to the preparation of nurses for clinical decision making and judgment. Most philosophies for nursing curricula contain some mention of it and thus it is useful for faculty to discuss its place in the curriculum and how it applies to its specific nursing program. Chan (2013) conducted a review of the international literature on critical thinking in nursing and identified themes related to the definition of critical thinking as it applies to nursing. From the review, she identified the characteristics of critical thinkers as “(i) gathering and seeking information, (ii) questioning and investigating, (iii) analysis, evaluation, and inference, and (iv) problem solving and application of theory” (p. 237). Four major influences on the development of critical thinking include the student, teacher, educational system, and the environment. In addition, some of the articles described strategies for developing critical thinking but as the author points out, further study is indicated to assess the efficacy of these strategies.

LIBERAL EDUCATION AND THE SCIENCES

One of the essential skills taken from the liberal arts and integrated into nursing education is the ability to write effectively. Troxler, Vann, and Oermann (2011) 194conducted a review of the literature related to the development of writing skills in undergraduate nursing programs. The purpose of the study was to identify various strategies for developing writing skills that are essential to nurses’ communication skills in their relationships with patients and in the written word. Among the strategies identified in the review were key writing assignments across the curriculum, intensive nursing writing courses, ombudsman programs, and online writing tutorials.

Pavil (2011) reviews the connections between the arts and nursing education and practice. She reviews the literature that identifies instructional strategies for fostering creativity in nursing through artistic expression such as poetry, painting, music, sculpture, and so on. To integrate the liberal arts with nursing, and use creativity, students write a scholarly paper on a case study of a clinical experience with a patient and create a presentation to their peers that depicts the experience, such as role playing, reciting a poem, painting, music, and so on. Students, although reluctant about the assignment at first, expressed their enthusiasm about the experience and the opportunity to blend the arts with nursing.

Lapum et al. (2012) describe the integration of the social sciences into nursing education with experiences for students to investigate social justice issues and begin to assume the role of advocate for the oppressed. The authors describe how the teacher presented a poem applied to an oppressive experience in which she was involved and had the students write notes on their reactions to the story. The notes were assembled into a continuing poem and provided the teacher and students the opportunity not only to explore social justice issues and experience the negative feelings associated with them, but also to enter a threshold for developing solutions to the problems. The article illustrated the integration of the social sciences into education and practice and it demonstrated a strategy for participative student learning.

The integration of the liberal arts into nursing practice was studied by DeBrew (2010) when comparing the perceptions of RN to bachelor of science in nursing (BSN) and prelicensure BSN graduates. DeBrew describes AACN’s (2014c) Essentials for Baccalaureate Nursing and the application of the liberal arts to nursing. The author surveyed RN to BSN and entry-level BSN graduates (n = 92) and found that the RN to BSN and entry-level BSN graduates were quite similar in their responses to the value of the liberal arts. The graduates reported that the liberal arts helped them communicate with patients, contributed to cultural competence, provided an academic background to grow professionally, and caused them to think globally and critically, which supported clinical decision making.

As a capstone experience in undergraduate work, Beuttler’s (2012) persuasive essay argues for a return to a senior level moral philosophy course to integrate knowledge from the liberal arts. He reviews how American education moved away from the liberal arts and became more discipline specific. He argues that if institutions say in their missions, visions, and philosophies that they prepare graduates with moral character, good citizenship, leadership qualities, self-reliance, and worldviews, there should be a senior level course to integrate the liberal arts knowledge gained. Professional education, such as nursing, usually has senior-level capstone courses for the purpose of integration of knowledge gained through the previous years. However, 195as Beuttler points out, there needs to be a similar course that integrates the liberal arts to ensure the preparation of graduates who have strong moral characteristics.

To demonstrate the critical contribution that science has to nursing, Wolkowitz and Kelley (2010) surveyed 149 directors of associate degree, baccalaureate, diploma, and practical nurse nursing programs who utilized the Test of Essential Academic Skills (TEAS). TEAS assesses entrance into academe. They also utilized the Assessment Technology Institute (ATI) results to assess students’ knowledge of the fundamentals of nursing. Multiple regressions compared science, mathematics, reading, and English TEAS scores to successful completion of student scores on the ATI fundamentals. They found that science was the major factor contributing to success in the fundamentals of nursing.

Along with the traditional requisite sciences of anatomy, chemistry, microbiology, nutrition, and physiology for nursing, genetics is now included in most programs as a separate course or integrated throughout the curriculum. The AACN Essentials documents (2014b) include genetics as part of the essentials. The continual breakthroughs of knowledge from the National Human Genome Project (HGP) illustrate the important contributions genetics have on the health of individuals. The latest information from the HGP may be found at www.genome.gov/10001772 (2014). Several articles on the integration of genetics into the curriculum that may be helpful to nurse educators as they plan a curriculum include DeSavo (2010); Lea, Skirton, Read, and Williams (2011); and Tonkin, Calzone, Jenkins, Lea, and Prows (2010).

THE HEALTH CARE SYSTEM, ORGANIZATION, POLICY, FINANCE, AND REGULATION

Knowledge of how the health care system is organized, financed, and regulated is essential for nurses to understand how it functions and nursing’s role in it. Nurses must be prepared to provide leadership in the management of health care services and to address policy issues. The current organizational system of health care in the United States is in a state of flux owing to the enactment and implementation of the Affordable Care Act of 2010 with its legality subsequently upheld by the Supreme Court in 2012. Pulcini (2013) provides an update on its implications for patients and nursing including health insurance coverage in a competitive market, expansion of Medicaid benefits, availability of prescription medications, and the impact on advanced practice nurses’ services and reimbursement. The federal government provides the full text of the Act and updates related to it at www.hhs.gov/healthcare/rights/law/index.html (U.S. Department of Health and Human Services [HHS], 2014).

Nurses are first in a Gallup poll as being the most ethical of professions (Nurses earn … 2014) and, in the same article, the American Nurses Association (ANA) encourages policy makers to involve nurses in key health care groups such as advisory and governing boards and working with coalitions of consumers, politicians, and professionals. How to prepare nurses for leadership in the health care arena should be part of the discussion by faculty when developing the philosophy for the curriculum. Faculty’s beliefs about the health care system’s organization, 196regulations, and financing are reviewed and the profession’s responsibility in shaping public policy should be part of the educational program.

The extent of the education and experiences for students on these issues will vary according to the level of education, that is, entry-level or advanced nursing. Logan, Pauling, and Franzen (2011) present the Grand View Critical Analysis model as a tool for baccalaureate nursing students to examine and analyze a health care issue, focus on the issue, form colleagueships to address the issues, analyze evidence-based practice related to the issue, and develop a proposal related to the issue with an action plan to carry it out. This type of activity builds leadership skills for nurses in the policy-making arena.

On the graduate level, Aduddell and Gorman (2010) present an example of how their nursing program for advanced practice nurses integrated concepts on health care theory, research, ethical leadership, health policy with global application in health care systems, principles of evidence-based practice, and leadership in advanced care management. Courses related to these topics were presented to advanced practice students as well as those in the nursing leadership and management track. Students had the opportunity to apply theories and concepts from the courses to their practica, thus solidifying the assimilation of leadership skills in the health care system and policy-making environments.

To gain an appreciation on the costs of health care in the United States, Nickitas (2013) cites examples of high-cost medical procedures compared to other Western countries. For example, U.S. costs of caesarian sections, colonoscopies, and other diagnostic tests far exceed the costs in other nations. She reports that the total cost of care in America is $2.7 trillion and that many of the costs may be attributed to insurance companies and hospitals generating revenue for their maintenance at the expense of the consumer. Such factors are important for nurses to be aware of when helping to shape policy as well as when providing services that may not be necessary and are costly.

The health insurance industry covers the vast majority of health care costs incurred in the current U.S. health care delivery system. Kelly (2013) presents an overview of the health insurance industry and its lack of competition in the market. The article traces the history of the skyrocketing costs of health care including the Medicare, Medicaid, and the VA systems. It illustrates the need for leaders in health care to influence health policies through legislative action. The implementation of the Patient Protection and Affordable Care Act (PPACA) of 2010 will cause major changes in the health care industry, resulting in a competitive health care marketplace. Updates on these issues and their effect on nursing are necessary in the preparation of professionals for the health care system.

CLINICAL PREVENTION AND POPULATION HEALTH

A primary resource when planning the curriculum that includes clinical prevention, population health, and health promotion is the Healthy People 2020 (2012) document that lists the 10-year national objectives for improving the health of all Americans. Implications for nursing education come from the document and include the need for knowledge of epidemiology, population health, determinants 197of health, and disparities to achieve health equity for all groups. Healthy People 2020, HHS announces new health promotion disease prevention agenda (2012) brought to the attention of its members the importance of the Healthy People 2020 agenda and the role of nursing in realizing its goals. An example of nursing responding to this agenda is presented in an editorial by Berg and Pace (2010) and followed by a series of articles focused on nurse practitioner services in women’s health focused on health promotion, risk reduction, and prevention of diseases.

Majette (2011) reviews the U.S. Congress deliberations related to the development and enactment of the PPACA of 2010 as it relates to health promotion and prevention of disease. As an insider in the process, she identified specific content in the act that was discussed by Congress and addressed public health, wellness, and prevention recommendations from such entities as the Institute of Medicine (IOM) and national and international health and human rights organizations.

Diversity and Cultural Competence

When considering clinical prevention and population health, an important concept to include is diversity. Diversity is defined in its broadest sense not only in terms of race, ethnicity, culture, language, and gender but also in terms of the diversity of opportunities in nursing. Thus, when faculty develops the philosophy, it must consider these factors and how the curriculum will meet society’s diverse health care needs from entry-level graduates who function in all settings to those in advanced nursing roles in primary and tertiary care settings. Nursing care requires cultural sensitivity and awareness of differences among groups, while cultural competence denotes the knowledge and skills required for delivering care in cross-cultural situations. Dudas (2012) conducted a review of the literature regarding cultural competence and its evolution in nursing education. She points out the increasing diversity in the student population, although it still lags behind that of the general population, and the need for integrating the concepts into the educational program related to cultural diversity and the development of cultural competence.

Adeniran and Smith-Glasgow (2010) discuss the need for nurse educators to recognize diversity in learners including culture, language, gender, and learning styles. Bednarz, Schim, and Doorenbos (2010) discuss strategies for working with the increasingly diverse nursing student population. Although many articles are in the literature discussing diversity and its integration into entry-level nursing programs, Comer, Whichcello, and Neubrander (2013) describe a master’s level curriculum that prepares nurse leaders for the delivery of quality diverse cultural and linguistic services in the health care system.

An update on the standards for culturally competent care was developed through a review of the literature and relevant resources by Douglas et al. (2011). In addition to the review, the authors called for comments on the Internet from nurse clinicians and nurse educators worldwide to gather ideas. The findings and comments were synthesized into a table of worldwide nursing standards for the delivery of culturally competent care. The general categories for the standards include social justice, critical reflection, knowledge of cultures, cultural competence 198in health care systems and organizations, patient advocacy and empowerment, a multicultural workforce, education and training in culturally competent nursing care, cross-cultural communication and leadership, and evidence-based practice and research.

INTERPROFESSIONAL COMMUNICATION AND COLLABORATION

In the past, nursing and other health care disciplines recognized the need for interprofessional education, and with the complexity of the current U.S. health care system, it is an important concept to include in discussions and planning for the educational program. The AACN (2014a) and other professional education organizations support the IOM’s (2010) recommendations that call for interprofessional collaboration to meet the health care needs of the population.

Thibault (2011) reviews the IOM (2010) recommendations regarding The Future of Nursing and the Josiah Macy Jr. Foundation’s work to promote interdisciplinary education and its relationship to nursing’s role in the delivery of health care. Thibault presents an overview of what interprofessional collaboration means and how the health care professions need to move out of their silos in order to deliver comprehensive and quality care to patients. He emphasizes the need for leadership from the top administrators in health care professions education; careful planning in advance of students’ learning experiences; clinical experiences that take place over the continuum, that is, not in isolated experiences; interprofessional students experiences with new technologies such as patient simulations; and the need for faculty development to encourage commitment to interprofessional education and to promote new pedagogies involving interprofessional collaboration. Thibault reports that while the majority of projects sponsored by the Macy Foundation were between nursing and medicine, some of the projects involved other health care disciplines.

Several examples from the literature exemplify the collaboration among other disciplines and serve as models for developing curricular experiences that are interdisciplinary in nature. Milton (2012) offers definitions of interprofessional and interdisciplinary education and presents some ethical implications associated with the implementation of such programs from a nursing point of view.

Dacey, Murphy, Anderson, and McCloskey (2010) conducted a pilot study for undergraduate health psychology, pharmacology, premedicine, and nursing students to introduce them to each discipline and promote cross collaboration. While the sample was small, it was successful in developing the students’ skills for patient-centered care and an appreciation for other health care professions. Sheu et al. (2010) studied student-run clinics for medical, nursing, and pharmacy students to deliver interprofessional services to poor and underserved people. Several instruments to measure interprofessional attitudes were utilized and while quantitative findings were mixed, they found that there was an increased appreciation for interprofessional learning among the student groups. Interestingly, nursing students scored higher on the Readiness for Interprofessional Learning Survey, to which the authors comment, “that they may enter school with a different perspective, or that unique characteristics of their curricula, such as earlier clinical exposure, may change their perspective” (p. 1068).

199Matthews, Parker, and Drake (2012) describe a service-learning, interprofessional experience of communication disorders, nursing, physical therapy, and social work students who visited older adults in the community. The experience was very positive for clients as well as the students, who gained an appreciation for other disciplines’ roles as well as skills in working with geriatric clients. A unique perspective to this project is the partnership developed between the school and the community in providing clinical experiences for the students.

PROFESSIONALISM, PROFESSIONAL VALUES, AND NURSING PRACTICE

Nursing has the largest number of professionals in the U.S. health care system and while it has many pathways for entry into professional practice, it meets the criteria of a profession. Criteria for a professional discipline require a specific body of knowledge with members who study and practice the discipline. It includes specific ethics, and theories, and it produces relevant research. Smith and McCarthy (2010) discuss the AACN Essentials documents (2014c) and the recommended standards for education at the various levels of professional nursing practice, that is, the generalist (baccalaureate), the advanced generalist (master’s), and the advanced practice practioner (DNP). The article by Smith and McCarthy provides guidelines for determining the concepts of professionalism at certain curricular levels and what constitutes the discipline (profession) of nursing.

Miller (1988) presented a model of professionalism in nursing that had at its core, education in a university setting, and scientific knowledge as a basis for the discipline. She listed attributes of nursing professionalism as adherence to the ANA (2014) Code of Ethics, a community service orientation, professional organization participation, autonomy and self-regulation, publication and communication, the development and use of research, and continuing education and competence. All of these concepts can serve as discussion points when developing this thread in the curriculum. For ideas on presenting concepts related to professionalism, Rhodes, Schutt, Langham, and Bilotta (2012) use Miller’s Wheel of Professionalism in Nursing for introducing professionalism to undergraduate nurses. They describe the learner-centered strategies for discussion of professionalism and its application to nursing.

SOCIAL JUSTICE AND ADVOCACY

Many of the standards for accreditation of nursing programs and requests for proposals for educational funding refer to the notion of inequality, health disparities, and access to health care. Certain populations and oppressed groups suffer the consequences of discrimination and unfair treatment in the health care system. Nursing as a prime caring profession must be cognizant of these injustices and have the power and strategies to advocate for their clients and themselves to provide quality health care for all. Social justice is an important concept often found in the missions and philosophies of educational programs; however, it is sometimes difficult to find evidence of its integration into the curriculum plan and its implementation.

200Fahrenwald, Taylor, Kneip, and Canales (2007) present several characterizations of social justice from a nursing perspective and the importance of it to nursing education and practice. They review the complexities of social justice and the need to analyze it from many viewpoints and its role in the discipline of nursing. Traditionally, social justice is taught in public health courses; however, the authors point out that it transcends all specialties in nursing and needs to be integrated throughout the curriculum. In addition to analyzing the characteristics and concepts related to social justice, they advocate for its presentation in the nursing program through transformative learning activities. They believe that learners must participate in confronting issues related to social justice to become leaders in the health care system and advocates for the people who suffer health disparities and limited access to quality care. This idea applies to all concepts related to the philosophy that guide the curriculum and returns to the theories related to teaching and learning. Each concept discussed and integrated into the philosophy and program of study must be considered by faculty for how it will be presented to students and how students will interact with it to assimilate and practice what the program defines as expectations for its graduates.

Lathrop (2013) discusses the social determinants of health with an emphasis on socioeconomic status in the United States and cites statistics that demonstrate the effect of one’s place in the economy on health outcomes. For example, the poorest people experience higher morbidity and mortality rates those who are economically advantaged. She goes on to say that nursing leaders, as advocates and representatives of the caring profession, should have a role in bringing attention to the social determinants of health to the nation and its policy makers. Additionally, she urges nurse educators to bring these issues into the curriculum and suggests ways in which students can participate as advocates for the economically and socially disadvantaged.

SCHOLARSHIP, RESEARCH, TRANSLATIONAL SCIENCE, AND EVIDENCE-BASED PRACTICE

Scholarship and Research

Scholarship and research provide the foundation for evidence-based practice. Both concepts appear in nursing curricula and should be addressed by faculty when developing or revising the philosophy of the educational program. Scholarship and research concepts begin at the associate degree level and continue in complexity to the PhD where new knowledge is tested and added to the body of scientific knowledge for the discipline. Faculties identify the scholarship and research competencies they expect of their graduates according to the level of the educational program and the practice areas or role functions that they expect their graduates to achieve. For example, associate degree programs expect their graduates to use evidence-based practice based upon credible, research-based nursing interventions and to challenge practices that lack data to support their use and do not result in quality patient outcomes.

Baccalaureate programs usually require a basic statistics course to support a separate nursing research course in the curriculum with expectations that graduates 201will understand the research process so that they can be discerning consumers of the research literature and use it to provide evidence-based practice. Writing assignments across the curriculum develop students’ scholarly skills to review, analyze, and critique the literature in order to communicate professionally and apply evidence from the literature to practice. Greenwald (2010) describes the role of undergraduate research in light of faculty’s own research needs and expectations and the development of scholarship skills in students. She reviews Boyer’s (1990) statements of scholarship in academe and their relationship to research in nursing education.

Most graduate nursing programs require graduate level statistics and research in nursing courses. They usually have capstone options for theses, scholarly projects, professional papers, advanced practice projects, or research-focused dissertations. Many include comprehensive examinations in addition to the written paper or dissertation or sometimes as the only capstone requirement. The thesis at the master’s level can serve as a pathway to doctoral studies and uses extensive reviews and analysis of the literature in addition to utilization of research processes to investigate a problem. Projects or other scholarly works and professional papers at the master’s level include extensive reviews of the literature and their integration to support the project or paper. At the doctoral level, both research-intensive and applied research projects require supporting research and statistical analyses courses. The number and depth of knowledge and research contained in these courses depend upon the type of doctoral program. Research-based PhD or DNS dissertations synthesize knowledge of nursing science on a selected topic and generate new knowledge through quantitative, qualitative, or mixed method processes.

Regan and Pietrobon (2010) present ideas about scholarly writing and its application to the dissemination of research findings. They point out that graduate education programs often require scholarly and evidence-based written papers/dissertations that specify what format the content of the paper should take but fail to use a conceptual model for the writing format. They offer a conceptual model for scholarly writing composed of four principles and suggest a course revolved around them for students. The principles (rhetoric, ethnographic, recognition, and practice) offer different perspectives on style of writing according to the discipline and type of research reported upon.

Translational Science

Translational science is a relatively new discipline in health care and applies to the analyses of research and current practice and applies these analyses to practice. One of the newest institutes at the National Institutes of Health is the National Center for Advancing Translational Sciences (2014), which offers opportunities for health care professionals to apply research to practice. Grady (2010) offers a definition for translational research as it applies to nursing:

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