Curriculum trends in nurse practitioner programs: Current and ideal

ORIGINAL ARTICLES Curriculum Trends in Nurse Practitioner Programs: Current and Ideal JAMS P. BELLACK,

PHD, RN, FAAN,* DAVID

EDWARD H . O ' N E I L , P H D , {

*Associate Provost for Education and Professor of Nursing, Medical Universityof South Carolina,Charleston,SC; and Senior Fellow,Center for the Health Professions,Universityof CaliforniaSan Francisco,San Francisco,CA. tAssociate Professor, Department of Health Administration and Policy,MedicalUniversityof South Carolina, Charleston,SC. $Codirector, Center for the Health Professions, Universityof California-San Francisco, San Francisco, CA; and Executive Director, Pew Health Professions Commission, San Francisco, CA. ~Associate Professor, EnvironmentalHazards Assessment Program, MedicalUniversityof South Carolina, Charleston,SC. qJAssociateProfessor, Department of Biometryand Epidemiology,MedicalUniversityof South Carolina, Charleston,SC. Partial funding provided by the National Fund for Medical Education through the Center for the Health Professions, University of California-SanFrancisco,San Francisco,CA. Address correspondence and reprint requests to Dr Bellack: Medical University of South Carolina, Administration Bldg, Room 200G, 171 AshleyAve, Charleston,SC 29425. Copyright © 1999 by W..B.SaundersCompany 8755-7223/99/1501-0007510.00/0

Journal of ProfessionaINursing, Vol 15, No

PHD,t

CATHERINE MUSHAM, PHD,.~

AND CAROL LANCASTER,

The purpose of this study was to ascertain the extent to which nurse practitioner (NP) education programs are addressing curriculum topics related to practice competencies needed for the next century as recommended by the Pew Health Professions Commission and other professional organizations, including the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. The study was part of a comprehensive survey of 11 health professions education programs. NP program directors indicated greatest dissatisfaction with curriculum coverage of "use of electronic information systems" and "business management of practice." The three most important curriculum topics identified by respondents were "primary care," "health promotion/disease prevention," and "effective patientprovider relationships/communication," identical to

R. GRABER,

PHD¶

the three topics rated most important by all groups combined. The most significant barriers to change identified by the respondents included "an already crowded curriculum" and "limited availability of clinical learning sites." Findings show that NP program directors perceive that they are doing an effective job addressing most of the 33 curriculum topics, but they also recognize a need to continue to improve their curricula in response to the ever-changing health care environment. Barriers to achieving the desired curricular improvements, however, may be significant. Recommendations for overcoming these barriers to change are offered. (Index words: Curriculum change; Nurse practitioner education; Practice competencies) J Prof Nurs 15:15-27, 1999. Copyright © 1999 by W.B. Saunders Company

H E US HEALTH CARE system has undergone rapid and unprecedented change in the final decade of the twentieth century. As the system continues to evolve in response to market forces, federal and state debates on reform, and concerns about cost, quality, variability, and access, health professions educators face pressing demands to revamp the educational programs that prepare practitioners for practice in this rapidly changing system. Although the public focus on health care reform has emphasized issues of managed care, cost control, payment, and regulation, real and lasting improvements in health care delivery and financing ultimately depend on changes in the education and competencies of those who will actually provide the care (Berwick, 1994; Shugars, O'Neil, & Bader, 1991a). As Berwick (1994) notes, "Only those who provide care can in the end change care" (p. 797). To adequately address such

T

1 (January-February), 1999: pp 15-27

15

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a task, health professions educators must consider no less than fundamental restructuring of the professional curriculum and methods of teaching. Since the early 1990s, the Pew Health Professions Commission and others have put forth calls for such fundamental reform (O'Neil, 1993; Pew Health Professions Commission, 1995a, 1995b; Shugars et al., 1991a). These proposals reflect a common theme: to meet the demands of a new health care system, innovative programs must be developed to ensure that graduates have the knowledge, skills, and values to practice effectively in the evolving systems of health care delivery and financing. Changes must be made in the way health professionals are educated "upstream" to have a significant impact on health care access, cost, and quality "downstream" (Batalden, 1997; Shugars, et al., 1991a). The Pew Health Professions Commission (1995a) has been a leading voice in articulating the need for reform in health professions education, asserting that "The transformations demanded of health practitioners and the educational programs that produce and support them are so enormous as to be dislocating" (p. x). Yet it is not clear that those who lead and teach in the programs that prepare future health care providers have begun to respond with the fundamental reforms that are so sorely needed; there is little evidence that true reform has yet occurred. Changes in curricula and learning experiences have tended to be add-ons, ie, increasing length and/or intensity of program requirements, rather than significant and essential reform. Some of this lack of movement may be attributed to the complexity of the task of change and the enormity of the challenge. The latter half of the twentieth century has witnessed a vast proliferation of knowledge and information, making it increasingly difficult for programs to teach all there is to know. This expanding knowledge base also finds faculty often engaged in revenue-generating research and clinical practice, taking time away from teaching and mentoring students. Many of the new competencies demanded of the next generation of health professionals fall outside the knowledge and experience of many faculty practicing today. Furthermore, it is apparent that the increasingly relevant locations for clinical education are in ambulatory and community-based sites outside the traditional acute care hospital. These and other forces create a compelling case that the current model of health professions education will no longer produce graduates prepared to practice in the health care system of the future, regardless of the level of resources available to it. To ensure that

BELLACK ET AL

essential competencies are acquired by students and that the learning process is managed in ways that allow faculty to fulfill their multifaceted roles as educators, researchers, and clinicians, new structures and processes for education must be created. Several key nursing organizations have issued position statements, curriculum guidelines, and descriptions of essential core content and competencies that affirm generic recommendations for change in health professions education with specific application to advanced nursing practice (American Academy of Nurse Practitioners, 1993; American Association of Colleges of Nursing [AACN], 1993, 1996; American College of Nurse Midwives, 1993; American Nurses Association lANAI, 1995; National Organization of Nurse Practitioner Faculties [NONPF], 1995). All call for new and expanded competencies to ensure that advanced practice nurses are adequately prepared for the practice challenges they will face in a highly volatile and ever-changing health care system. But it remains to be seen whether these competencies can be achieved within the current array of programs, schools, faculty, and professional and regulatory oversight. Nurse practitioner (NP) education programs that prepare providers for independent and collaborative practice roles in primary health care settings must ensure their graduates' readiness to meet the demands they will face as providers with increasing responsibility and accountability for health care management and decision making at the frontline. As one of the fastest growing groups of primary care providers, NPs need a broad repertoire of skills to work effectively with individual patients and families while negotiating the larger health care system in which they practice.

•.. new structures and processes for education must be created.

To date, however, no comprehensive survey of NP education programs has been conducted to determine to what extent programs have moved toward a restructuring of their curricula in response to the many national calls for change. Are programs currently emphasizing the competencies that are essential for effective practice, both now and into the future? If not, to what extent do they aspire to do so? And what barriers do they face to achieving curriculum change?

CURRICULUMTRENDS IN NP PROGRAMS Essential Competencies

The competencies needed for effective primary care practice in the changing health care system have been well-delineated and substantiated by the Pew Health Professions Commission (O'Neil, 1993; Pew Health Professions Commission, 1995a, 1995b; Shugars et al., 1991a) and others (AACN, 1993, 1996; ANA, 1995; NONPF, 1995). The competencies that are especially pertinent to primary care practice are listed in Table 1. Ensuring that a program's graduates acquire these broad competencies is certainly a tall order, but it is one that must be filled if NPs are to deliver effective primary care and be assured a place in an increasingly managed system of health care. To determine the extent to which NP curricula currently include content and learning experiences specific to these competencies, or would like to include them, a survey of NP programs was conducted as part of a larger study of curriculum trends in health professions education.

Purpose

The purpose of this study was to ascertain the extent to which health professions education programs address curriculum topics related to the recommended practice competencies. This NP study was part of a comprehensive survey of 11 health professions education programs to determine the extent to which they are responding to recommendations from the Pew Health Professions Commission (O'Neil, 1993; Pew Health Professions Commission, 1995a, 1995b; Shugars et al., 1991 a) and other professional organizations (AACN, 1993, 1996; Association of American Medical Colleges, 1992; Field, 1995; NONPF, 1995). Other groups surveyed for the study included undergraduate allopathic and osteopathic medicine, dental medicine, nurse midwifery, pharmacy (pharmD), physician assistant, and four primary care graduate medical residency programs: family medicine, internal medicine, general pediatrics, and obstetrics-gynecology. Programs were selected for inclusion because of their strong focus on preparing graduates for generalist and primary care practice roles. The assumption was made that these programs would be the ones most likely to heed calls for education reform given the increasing emphasis on primary care within the evolving health care system. This survey of NP and other health professions

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TABLE 1. Competencies for Effective Primary Care Practice Promote, protect, and improve the health of the community in partnership with and in service to the community Adopt a population perspective of health, including understanding the epidemiology of health Expand the availability and accessibility of health care, especially for underserved populations, in settings appropriate to the population being served Provide coordinated, continuous, comprehensive, and compassionate primary care Communicate clearly, respectfully, and effectively with patients, families, and other professionals Promote health and prevent disease/illness using primary and secondary prevention strategies Reduce environmental health hazards Involve patients and families in decision making about their health care Demonstrate sensitivity and respect for diversity, including differences related to age, gender, culture, race-ethnicity, socioeconomic status, and ability Balance issues of personal and professional ethics and values, patient preferences, system regulations, and health care resources with an understanding of how differences may create conflicts of interest Understand health care ethics and decision making and counsel patients and families when ethical issues arise Work effectively in interdisciplinary teams and integrated systems of care across the continuum of care settings (outpatient and ambulatory, long-term care, home, and, as appropriate, acute care) Understand health policy and legislation, health care economics and financing, and health care organization and administration Apply principles and processes of continuous quality improvement to the delivery of health care Demonstrate accountability for cost-effective, appropriate, and high-quality health care at individual, team, institutional, profess~onal, and system levels Evaluate and use available technology appropriately Access, analyze, and synthesize large volumes of scientific and patient information, selecting and using that which is relevant and appropriate Use computer-based information and practice management systems to access and manage data, support decision making, and access professional literature and learning resources for clinical application and continuing competence Know and use accepted clinical practice guidelines Maintain clinical competence congruent with professional values and standards and accepted practice Engage in lifelong professional development Data from American Association of Colleges of Nursing (1993, 1996), American Nurses Association (1995), O'Neil (1993), Pew Health Professions Commission (1995a, 1995b), National Association of Nurse Practitioner Faculties (1995), Shugars et al. (1991).

education programs sought to answer the following questions: . To what extent are selected curriculum topics currently included in the required learning experiences of the program?

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2. To what extent do program directors believe the selected curriculum topics should be included in the required learning experiences of the program? 3. What do program directors believe are the most important curriculum topics to assure that their graduates are prepared adequately for practice in the evolving health care system? 4. What do program directors identify as the barriers to needed curriculum change in their respective programs?

Methodology SAMPLE

A total of 1,770 programs were surveyed for the comprehensive study. Surveys were mailed to academic deans, program directors, or curriculum directors in each of the survey groups. The nurse practitioner survey was mailed to the 140 (NP) program directors whose names and addresses were provided by NONPE Because NONPF's mailing list does not identify programs by program type, one limitation of the study was that directors of non-primary care NP programs also received the survey questionnaire. This is important to note because some of the curriculum topics included in the questionnaire were not relevant for certain specialty NP programs, eg, "care of the elderly" for neonatal NP programs. The Total Design Method, pioneered by Dillman (1978), was used for the survey format. This method employs a booklet format with an illustrated color cover. Surveys were color-coded for each survey group and also coded by individual program. A copy of the four-page, color-coded survey instrument, a cover letter, a stamped return envelope, and an assurance of confidentiality were mailed to each NP program director. A postcard was mailed to the full sample 1 week after the initial mailing as a reminder to complete and return the questionnaire. A second mailing was sent 1 month after the first mailing to those program directors from whom a response had not been received. A total of 966 usable completed surveys from the comprehensive study were returned, for an overall response rate of 55 per cent. The response rate for NP programs was 60 per cent (84 usable returns). SURVEY INSTRUMENT

The survey instrument consisted of 46 items in a five-point Likert scale format ("Not at all" to "To a

great extent") and one open-ended question for comments. The first section of the questionnaire included 33 curriculum topics arranged in the following categories: general, patient-provider relationships, health care delivery, health care organization, and clinical practice. For each of the 33 topics, respondents were asked to indicate the current emphasis placed on the topic in the required learning experiences in the curriculum and also to indicate the extent to which they believed each topic should be included in the required learning experiences (ideal emphasis). At the end of this section, respondents were directed to "circle the numbers of the three curriculum topics... that you believe are most important to assure that your graduates are prepared adequately for practice in the evolving health care system." The second section of the survey instrument focused on perceived barriers to curriculum change. Using the same five-point Likert scale, respondents were asked to what extent each of 12 factors listed would be a barrier to curriculum change in their own program. A thirteenth item, "Other," allowed respondents to specify an additional factor not listed and rank the extent to which the respondent perceived it as a barrier. The same questionnaire was used for all target groups. The rationale for using the same survey instrument for all disciplines was the fact that the essential competencies and their related curriculum topics are relevant and important for all primary care providers. Although discipline-specific competencies are an equally essential aspect of preparation for primary care practice, this study was not intended to address them. Furthermore, the investigators were interested in differences that might exist among the different disciplines that prepare primary care providers with respect to the relative importance they place on the each of the curriculum topics. The questionnaire was developed by the investigators. Curriculum topics were selected for inclusion based on the frequency with which they appeared in recommendations from national groups--including the Pew Health Professions Commission, AACN, and N O N P F - - a n d current literature on needed curriculum change in health professions education. Table 2 illustrates the high degree of congruence between the questionnaire topics and the domains and competencies of nurse practitioner practice (NONPF, 1995), lending further credibility to the survey instrument for the NP target group. All but six of the topics are addressed by the NONPF domains and competencies. O f those not addressed, three ("primary care,"

CURRICULUM TRENDS IN NP PROGRAMS

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TABLE 2. Domains and Competencies of Nurse Practitioner Practice

TABLE 2. (Cont'd) Domains and Competencies of Nurse Practitioner Practice

Domain: Management of client health/illness status Competencies in this domain specifically reflect these questionnaire topics Health promotion/disease prevention Epidemiology Community social problems Patients as partners in health care Communities as partners in health care Primary care Managed care Case management Long-term/chronic illness care Clinical practice guidelines Accountability for cost-effectiveness & patient outcomes Understanding & utilizing research findings Domain: Nurse-client relationship Competencies in this domain specifically reflect these questionnaire topics Cultural differences Professional values Effective patient-provider relationships/communication Patients as partners in health care Patient teaching-education Psychosocial care Domain: Teaching-coaching Competencies in this domain specifically reflect these questionnaire topics Cultural differences Patients as partners in health care Communities as partners in health care Patient teaching-education Psychosocial care Accountab~hty for cost-effectiveness and patient outcomes Domain: Professional role Competencies in this domain specifically reflect these questionnaire topics Cultural differences Legal aspects of health care Professional values Effective patient-provider relationships/communication Care for underserved patients/populations Health care economics and financing Health care policy Interdisciplinary teamwork Domain: Health care delivery systems Competencies in this domain specifically reflect these questionnaire topics Community social problems Legal aspects of health care Communities as partners in health care Managed care Case management Care for underserved patients/populations Health care organization and administration Health care economics and financing Health care policy Continuous quality improvement Clinical practice guidelines Accountability for cost-effectiveness and patient outcomes Understanding and utilizing research findings Interdnsciplinary teamwork Use of electronic information systems Business management of practice

Domain: Health care quality Competencies in this domain specifically reflect these questionnaire topics Legal aspects of health care Health care ethics Professional values Continuous quality improvement Clinical practice guidelines Accountability for cost-effectiveness and patient outcomes Understanding and utilizing research findings

Continued in next column

Curriculum topics not addressed explicitly by NONPF Environmental health Care of the elderly Outpatient/ambulatory care Home health care Tertiary/quaternary care Population-based care Data from National Organization of Nurse Practitioner Faculties (1995).

"home health care," and "tertiary/quaternary care") are setting specific and therefore would not necessarily be included in a list of general practice competencies. The three remaining topics that are not addressed specifically by the NONPF domains and competencies include "care of the elderly," "population-based health care," and "environmental health." However, age and human development are addressed, and it can be inferred that care of the elderly is an important component of family and geriatric NP programs. Additionally, the impact of environmental factors on health, although not specifically mentioned, also can be inferred from several of the NONPF competencies, including those of"community assessment," "epidemiology," and "health promotion/disease prevention services related to geographic location and risk." It is more difficult to conclude that the NONPF competencies address population-based care, which involves managing the health and illness of a population or panel of clients and being accountable for the health outcomes of that population. The N O N P F competencies related to health and illness management focus specifically on individual client care and not on managing a client population. Many of the survey's curriculum topics are potential course subjects or denote nontraditional settings for particular kinds of learning experiences. Other topics are philosophical or political in nature, suggesting a particular approach to health care delivery. Some hint at a departure from traditional health professions education. Some topics are broad; others are specific. The investigators concluded that such a mix of topics was the best way to address the wide range of

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recommendations for curriculum change made in recent years. The questionnaire was revised after receiving input from a focus group held with program directors in the investigators' home institution who represented the disciplines included in the study population. The revised survey was then pilot tested with 12 program directors representing the target disciplines and revised a final time before being mailed to the full sample. The questionnaire was designed to examine program directors' perceptions regarding current emphasis versus ideal emphasis on selected curriculum topics deemed essential to primary care practice, with one exception. "Tertiary/quaternary care" was included to determine if the directional change from current to ideal on this topic would differ from those topics that are more directly relevant to primary care. Also, the questionnaire was designed intentionally to elicit program directors' views on which topics deserve greater emphasis, not which topics they believe will actually receive greater emphasis. In other words, respondents were asked to express their preferences regarding curricular emphasis rather than predict what curricular changes they believe are likely to occur. On the basis of focus group findings, the investigators chose the word "ideal" to represent desired emphasis. Focus group participants validated that health professions educators readily understand that "ideal" means what they want as opposed to what they believe will happen. Furthermore, focus group participants did not take this to mean an ideal scenario in which all topics should receive more attention. They understood that the instructions called for them to differentiate among topics in ideal emphasis, an assumption that was confirmed by the survey findings. The focus group participants also understood the topics included were those that are, or should be, common across disciplines rather than disciplinespecific knowledge and competencies.

gram. It is not known if respondents whose schools have more than one NP program answered the items in a general sense for all their NP programs (or tracks) or for one particular program. It must be assumed, however, that respondents are knowledgeable about the NP curriculum whether one or several are offered by their respective school. In the same vein, the survey was designed to address broad curriculum topics pertinent to a variety of primary health care disciplines. Therefore, NP programs included in the survey were not differentiated by program type, as noted earlier. It is not known which specific program types are represented by the findings or whether respondents included other than primary care NP programs. Finally, the study was limited to curriculum topics and barriers to curriculum change and did not address such issues as teaching-learning strategies, faculty development, or the organizational factors involved in such change. Despite these limitations, the survey findings contribute to an understanding of desired future directions for NP education.

Findings Data from the 84 respondents were analyzed using descriptive and inferential statistics. For current and ideal emphasis for each of the 33 curriculum topics and for each of the 12 barriers, mean values were calculated, and Student's t tests were performed to compare differences between the responses of the NP program directors and those of the 10 other survey disciplines combined. Bonferroni procedure was used to adjust the critical values of the Student's t tests for the number of comparisons to maintain the error rate at 5 per cent. Findings from the NP program respondents are presented in three sections: 1. ratings by current and ideal emphasis,

LIMITATIONS

Several limitations of this study should be noted. First, although NP program directors are a knowledgeable group who likely exert considerable influence on the NP curriculum in their respective programs, they are not solely responsible for the curriculum. The findings of this survey, however, reflect only the views of the NP program directors and not all NP program faculty. Also, the survey was mailed to the NP program directors whose names were supplied by N O N P E Clearly, some schools have more than one NP pro-

2. most important curriculum topics, and 3. barriers to curriculum change. CURRENT VIDEAL EMPHASIS

Table 3 depicts the mean values for current and ideal emphasis rated by the NP program directors for each of the 33 curriculum topics. Respondents indicated that they desired an increase in emphasis for every topic, with the desired increase from current to ideal ranging from. 13 ("patient teaching-education") to 1.20 ("business management of practice"). Thus,

CURRICULUM TRENDS IN NP PROGRAMS

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TABLE3. Mean Values for Current and Ideal Emphasis for 33 Curriculum Topics Ranked by Ideal Emphasis Ideal

Difference

CurriculumTopic

Current

Health promotion-disease prevention Primary care Effective patient-provider relationships/ communication Patient teaching-education Professional values Patients as partners in health care Psychosocial care Outpatient/ambulatory care Cultural differences (beliefs, values, customs) Understanding and utilizing research findings Care for underserved patients/populations Community social problems Clinical practice guidelines Accountability for cost-effectiveness and patient outcomes Interdisciplinary teamwork Communities as partners in health care Use of electronic information systems Health care policy Biomedical/health care ethics Continuous quality improvement Managed care Case management Population-based care Epidemiology Legal aspects of health care Long-term/chronic illness care Health care economics and financing Health care organization and administration Environmental health Care of the elderly Business management of practice Home health care Tertiary/quaternary care

4.43§ 4.47

4.76§ 4.70

.33 .23

4.33 4.46§ 4.23:1: 4.24§ 4.325 4.39

4.69§ 4.59§ 4.56§ 4.56§ 4.55§ 4.54

.36 .13 .33 .32 .23 .15

3.71§

4 50§

.79

4.20§

4.46§

.26

4.11 4.44§ 3.93:[: 4.41:1: 4.12§ 4.41§

.33 .48 .29

3.695 3.86 3.615 3.07 3.495 3.48 3.38 3.301] 3.19 3 511] 3.191] 3.52§ 3.47 3 055

4.33§ .64 4.32 .46 4 315 .70 4.26 1.19r 4.16:1: .67 4.161] .68 4.10 .72 4.04 74 4.00 .81 4.001] .49 3.985 79 3.98§ .46 3.95 .48 3.891] .84

3.285 3.025 3.41 2.50 2.72 2.49

3.88:1: .60 3.84:(: .82 3.84 .43 3.70 1.2013 48 .70 2.72 .23

NOTE. On a scale of 1 to 5 (1 - Not at all, 5 = To a great extent), respondents indicated the extent to which each curriculum topic (1) is currently included in the required learning experiences (current emphasis) and (2) should be included in the required learning experiences (ideal emphasis). 1-Difference >1.00. SHighest among all survey groups. §Second highest only to nurse midwives. 1]Second highest only to one other (nonnurse) group.

across the sample the desired (ideal) emphasis is greater than current emphasis for every one of the 33 topics. The mean difference between current and ideal emphasis for all topics was .54 for NP programs compared with a mean difference of .66 for all programs combined. It is worthwhile to note that respondents rated the first eight topics listed in Table 3 highest for both current and ideal emphasis (4.23 or higher), with the

difference between current and ideal ranging from a low of.13 to a high of.36 for these eight topics (mean difference = .26). Thus, the NP program directors rated these topics highly in the emphasis they are currently receiving in their programs, desiring only a small increase in their emphasis. For most other topics, the discrepancy between current and ideal emphasis was substantially greater. The greatest differences between current emphasis and ideal emphasis occurred in the following topic areas (in descending order of magnitude of difference): "business management of practice," "use of electronic information systems," "healthcare economics and financing," "environmental health," and "case management," indicating that NP program directors perceive these topics in need of much greater emphasis. However, only the first two topics in this list had a difference between current and ideal greater than 1.00. This finding was substantially different from several other groups, the majority of which had higher numbers of topics (range, 4 to 15) for which the desired increase in emphasis was greater than 1.00. The NP program directors rated one third (n = 11) of the topics higher than 4 (on a five-point scale) for current emphasis, whereas more than two thirds (n = 23) were rated higher than 4 for ideal emphasis, indicating that respondents want to double the number of topics on which NP programs should be placing strong emphasis, ie, greater than 4 on a five-point scale. Furthermore, respondents rated 19 topics (58 per cent) highest or second highest of all survey groups for current emphasis, a difference that was statistically significant for 17 (52 per cent) of these topics (Table 4). The NP program directors also rated 21 topics (64 per cent) highest or second highest for ideal emphasis among all survey groups, a difference that was statistically significant for 19 (58 per cent) of these topics. The overall mean rating for the 33 curriculum topics for current emphasis was 3.64, whereas it was 4.19 for ideal emphasis. Table 4 shows that the differences between the NP program directors' mean ratings and those of all other survey groups were statistically significant for current emphasis for 22 (67 per cent) of the topics and for 21 (64 per cent) of the topics for ideal emphasis. Of these topics, only "tertiary care" showed significantly lower differences for both current and ideal emphasis compared with the other survey groups; the remaining topics were rated significantly higher than other groups.

Current Emphasis Within the larger survey, the NP program directors rated 9 topics (27 per cent) highest of all survey groups

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TABLE4. Statistically Significant Differences on Current and Ideal Curriculum Topics: Nurse Practitioner Programs Compared With all Other Survey Groups Combined Current Topic

t

Ideal P

t

Health promotion/disease prevention 6.75* .000 3.43* Cultural differences 5.83 ,000 10.07" Environmental health 4.50* .000 4.58 Community social problems 5.73 .000 5.53* Legal aspects of health care 4,77 .000 4.79 Professionalvalues 7.38* .000 5.04* Effective patient-provider relationships/communication 4.82 .000 3.52* Patients as partners in health care 8.98* ,000 5.92* Communities as partners in health care 7.82 .000 6.47 Patientteaching/education 11.08" .000 4.70* Psychosocial care 8.71" .000 6,78 Long-term/chronic illness care 3,27 .001 Tertiary care - 7 . 2 0 .000 -3.51" Care for underserved patients/ populations 5,07* .000 6,83* Population-based care 6,42 .000 4.44 Health care organization/administration 6.62 .000 5,56 Health care economics/financing 4,17 .000 4.39 Health care policy 8.65 ,000 7.74 Clinical practice guidelines 10.45" .000 7,29* Accountability for cost-effectivenessand patient outcomes 5.96 .000 4.40* Understanding and utilizing research findings 10.14" .000 6.35* Interdisciplinary teamwork 3.67 .000 4.77

P .001 .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .001 .000 .000 .000 .000 ,000 .000 .000 .000 ,000

NOTE. All values are pooled variance estimates except where noted. *Separate variance estimate.

for current emphasis: "professional values," "psychosocial care," "community social problems," "accountability for cost-effectiveness and patient outcomes," "communities as partners in health care," "health care policy," "health care economics and financing," "health care organization and administration," and "environmental health." All nine of these topics were above midpoint (>3) on the five-point scale. The findings also show that among the 11 survey groups, NP program directors rated their current emphasis second highest among all survey groups on an additional 10 topics: "health promotion-disease prevention," "patient teaching-education," "patients as partners in health care," "cultural differences," "understanding and utilizing research findings," "clinical practice guidelines," "legal aspects of health care," "managed care," "epidemiology," and "populationbased care." Thus, among all survey groups, NP program directors rated their current emphasis for more than half of the curriculum topics (58 per cent)

highest or second highest, 17 of which (52 per cent) were statistically significant (Table 4). The NP program directors rated only three topics below the midpoint (<3) for current emphasis: "business management of practice," "home health care," and "tertiary/quaternary care." Only the latter was statistically significant, however, compared with all other groups combined. /deal Emphasis For ideal emphasis, the NP program directors rated six of the curriculum topics highest among all survey groups ("community social problems," "communities as partners in health care," "health care policy," "epidemiology,.... health care organization and administration," "environmental health"), with all but "epidemiology" statistically significant. The difference between current and ideal emphasis for each of these topics ranged from .48 to .82. Among the 11 survey groups, NP program directors also rated an additional 15 topics second highest for ideal emphasis, thus rating 64 per cent of the curriculum topics highest or second highest for ideal emphasis, 19 of which were statistically significant (Table 4). All but one topic, "tertiary/quaternary care," were rated above the midpoint (>3) for ideal emphasis (Table 3), the exception being statistically significant compared with the other survey groups combined. MOST IMPORTANT TOPICS

The curriculum topics identified as most important by the NP program directors are listed in Table 5. There was an unusually wide range of responses to this item among NP program directors, with at least one TABLE 5. Most Important Curriculum Topics Topic

n

%

Primary caret Health promotion/disease prevention:l: Health care economics/financing Effective patient-providerrelationships/communication§ Accountability for cost-effectiveness and patient outcomes Communities as partners in health care Managed care Understanding and utilizing research findings

53 39 16 15

63 46 19 18

15 13 13 13

18 15 15 15

NOTE. Of the 33 curriculum topics, 30 were ranked as "most important" by at least one respondent. Respondents were asked to "Please circle the numbers of the three curriculum topics in this list (items 1 to 33) that you believe are MOST IMPORTANT to assure that your graduates are prepared adequately for practice in the evolving health care system." tRanked no, 1 by all groups combined. :!:Ranked no. 2 by all groups combined. §Ranked no. 3 by all groups combined.

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Discussion

TABLE6. Mean Ratings for Barriers to Achieving the Ideal Curriculum Barrier

NP Program All Directors Groups

Already crowded curriculum Inadequate funding Limited availability of clinical learning sites

4.16 3,88 3.83t

4.14 3.83 3 14

Scheduling conflicts Faculty resistance Lack of faculty expertise Professional "turf" issues Professional accreditation criteria Professional licensing requirements Student resistance Administration resistance Community resistance

2.94 2.79 2.73 2.76 2.51 2.41 2.16 2.11 1.63:1:

3.24 2.89 3.01 2.79 2.52 2.10 2.43 2.42 1.85

NOTE. No respondents listed or rated an additional barrier. Respondents were asked, on a scale of 1 to 5 (1 = Not at all, 5 = To a great extent), "In your opinion, to what extent will each of the factors below be a barrier to needed curriculum changes in your program?" Abbreviation: NP, nurse practitioner. 1-Statistically significant difference compared with all other groups (t = 5.29, P = <.001). $Statistically significant difference compared with all other groups(t -2.80, P .006).

respondent indicating 30 of the 33 topics as one of the three most important topics. Three of the 4 topics rated highest by the NP survey group were identical to the three rated highest by all groups combined: "primary care," "health promotion/disease prevention," and "effective patient-provider relationships/ communication." The latter topic tied with "accountability for cost-effectiveness and patient outcomes" among the respondents. BARRIERS TO CHANGE

Table 6 lists barriers to curriculum change, as perceived by the NP program directors, ranked in descending order. Three barriers, "an already crowded curriculum," "inadequate funding," and "limited availability of learning sites," were viewed as significant by the NP program directors, with all three rated 3.85 or higher (the next highest rating was nearly a full point lower). The difference between the mean rating of the NP program directors and all other survey groups for the barriers, "limited availability of learning sites" and "community resistance," was statistically significant (P < .001), with the former perceived as a significant barrier and the latter viewed as not significant. External barriers, such as "accreditation criteria," "licensing regulations," and "community resistance," were not viewed as particularly significant obstacles by the NP program directors despite the fact that the former two often are cited by faculty as reasons they are inhibited in making curriculum changes.

As a group, the NP program directors are generally satisfied with curriculum coverage of many of the topics surveyed. In fact, for 18 of the topics (55 per cent), respondents indicated less than .50 difference between current and ideal emphasis. Assuming that a difference of 1.00 or greater indicates relative dissatisfaction with curriculum coverage, respondents expressed such dissatisfaction for only 2 (6 percent) of the 33 topics. Thus, NP program directors perceive that they are doing a better job than many of the other survey groups in emphasizing these topics despite their desire to place significantly greater emphasis (>.5 difference) on 5 (15 per cent) of these topics: "accountability for cost-effectiveness and patient outcomes," "health care policy," "health care economics and financing," "health care organization and administration," and "environmental health." These findings reflect the traditional strengths of NP programs and also show that, as a group, NP program directors are aware of the importance of expanded coverage of topics that are receiving much attention in the current health care system. With their high ratings of so many of the curriculum topics, the NP program directors reflect the extent to which they value the core curriculum topics and related practice competencies. Respondents rated 16 topics highest or second highest among all survey groups for current emphasis and 21 topics highest or second highest for ideal emphasis. The only other survey group to come close to the NP program directors in rating so many of the curriculum topics so highly for both current and ideal emphasis was the nurse midwifery program directors, which tied with the NP program directors for current emphasis but rated two fewer topics highest or second highest for ideal emphasis. The NP program directors' overall mean ratings for both current and ideal emphasis--3.64 and 4.18, respectively--were higher than those of any other survey groups. Only three topics were rated below the midpoint (<3) on the five-point scale in coverage for current emphasis--"home health care," "business management of practice," and "tertiary/quaternary care"--and only the latter topic was rated below average for ideal emphasis. The NP directors clearly recognize the value and importance of these core curriculum topics in preparing their students for effective primary care practice. These findings are consistent with a Harris poll of other practitioners in medicine, dental medicine, nursing, and pharmacy commissioned by the Pew

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Health Professions Commission (Shugars, O'Neil, & Bader, 199 lb), in which the nurses surveyed expressed greater overall satisfaction with their preparation for practice than the other three groups. Although the NP program directors would like to devote more time in their curricula to each of the survey topics, their overall responses indicate that they are more satisfied with their coverage of these topics than every other survey group• The nursing profession's values place strong emphasis on caring, concern for the welfare of others, self-determination, empathy, respectfulness, authenticity, and acceptance of differences (AACN, 1986). Historically, the nursing profession has embraced the importance of health promotion and keeping people well, providing care to individuals and groups in community and primary care settings, and involving consumers in decisions about their care (AACN, 1998; O'Neil, 1993). Reflecting this tradition, the NP and nurse midwifery program directors shared the highest and second highest ratings among all survey groups for "health promotion/disease prevention," "patient teaching/education," "patients as partners in health care," "psychosocial care," "cultural differences," "community social problems," and "communities as partners in health care" for both current and ideal emphasis. In fact, the NP and nurse midwifery program directors rated "patients as partners in health care" 4.24 and 4.68, respectively, for current emphasis. They were the only survey groups to rank this topic higher than 4 on the five-point scale. However, all groups rated this topic 3.93 or above for ideal emphasis. A similarly noteworthy finding is that the NP, nurse midwifery, and physician assistant program directors rated "care for underserved patients/populations" highest among the 11 survey groups for both current and ideal emphasis, a reflection of the values held by these provider groups. And for current emphasis, they also were the only groups to rate "patient teachingeducation," and "professional values" higher than 4, "cultural differences" higher than 3.5, and "communities as partners in health care" higher than 3. Thus, they perceive themselves as providing satisfactory to above-average coverage of these topics in their current curricula, although they still wish to improve in these areas. But compared with other survey groups, it will be less of a stretch to reach their ideal. As noted earlier, only two topics reflected a difference greater than 1.00 between current and ideal emphasis as rated by the NP program directors. These topics--"use of electronic information systems" and

BELLACK ET AL

"business management of practice"--historically have not been included in nurse practitioner curricula. The discrepancy between current and ideal ratings on these topics may reflect the respondents' recognition of the changing practice environment--specifically, the increasingly prevalent use of electronic information systems for clinical data management and the increasing emphasis on managed care and cost-effective practice--and the skills their students must acquire to respond effectively to these changes. In summary, the NP program directors perceive that they are doing an effective job providing coverage of these essential core curriculum topics, confirming the Pew Health Profession Commission's (O'Neil, 1993) findings. The Commission's 1993 (O'Neil) report notes: As the health care needs of the public have evolved, the nursing education community has responded by producing more nurses who are patient advocates, patient care coordinators, nurse midwives, nurse practitioners, home- and community-based nurses, and patient educators• New demands will continue to be placed on nurses as care in the hospital becomes more complex and as health care outside the hospital expands to accommodate a broader range of needs of the general population• A growing pressure for more cost-effective and consumer-responsive health care, delivered in a system better managed than ever before, will cause important changes in the role of nurses and their relationships with patients. The . . . Commission believes the profession will face these challenges from a position of strength, since nursing's skills of collaboration, effective communication, and teamwork will be needed to support and practice in a changed system• (p. 30) •

.

.

• . . a n u m b e r of barriers are likely to p o s e a challenge to a c h i e v i n g the d e s i r e d curricular i m p r o v e m e n t s •

The NP program directors' responses also may reflect their awareness of the need to continually improve NP curricula as the health care and professional practice environments change. Their ideal ratings of the 33 topics, for which they indicate a desire to provide more coverage in every instance, indicate that they perceive the challenge that lies ahead of them. However, a number of barriers are likely to pose a challenge to achieving the desired curricular improvements. Respondents identified three barriers in particular

25

CURRICULUM TRENDS IN NP PROGRAMS

that they perceive are likely to pose the greatest challenges to curriculum change: "an already crowded curriculum," "inadequate funding," and "limited availability of learning site," all of which were rated 3.83 or higher. The next most highly rated barrier was nearly a full point lower at 2.94 ("scheduling conflicts"). The two top-rated barriers paralleled those rated most highly by all survey groups (Table 6). Most daunting is the respondents' strong agreement that the curriculum is already too crowded. However, adding topics or expanding coverage of existing topics--either in the classroom or through experiential learning activities and clinical experiences-without determining what topics or learning experiences can be reduced or eliminated will not address the need for fundamental curriculum reform. Although this study did not seek to examine specific strategies for eliminating barriers to curriculum change, it is evident that NP program directors and faculty must take a critical look at their current curricula to determine the extent to which they emphasize the development of the essential competencies or need to find ways to do so. The authors suspect that NP curricula, like other health professions curricula, place far too much emphasis on time-limited, discrete content instead of competencies for accessing such information, eg, electronic resources for acquiring the information "just in time" as it is needed. O f particular concern is that the NP and nurse midwifery program directors both rated the barrier, "limited availability of clinical learning experiences," higher than any nonnurse group. In fact, the NP directors' rating of this barrier was .79 higher than the mean rating for all groups, a statistically significant difference, indicating their very real concern about access to clinical settings for student learning experiences. This finding is congruent with the NONPF Workforce Policy Project study (Harper & Johnson, 1996), which found that 71 per cent of respondents identified "lack of clinical training sites" as a barrier to the development and expansion of NP programs, rating it second only to "faculty shortage." All groups combined, however, viewed "inadequate funding" as a very real barrier to making curriculum change, rating it second highest. The NP program directors agreed. Various explanations may account for this concern, including the following: 1. a need for more faculty to provide coverage for time- and labor-intensive learning experiences in the community;

2. the greater costs associated with communitybased and primary care learning experiences, especially those that occur off-campus; 3. costs associated with linking students in remote clinical settings to the home institution via educational technologies (Internet, compressed video, phone conferencing); 4. intense pressure on faculty to generate revenue through research or clinical practice; and 5. increasing reluctance of clinical sites to accommodate students unless they are reimbursed for the "lost revenue" associated with educating students. The barrier of inadequate funding is likely to become even more significant in the future as managed care and federal and state reimbursement policies result in greater pressure on providers and health care systems to contain costs while maintaining quality, with no allowances for the additional educational costs incurred or incentives for encouraging providers and systems to become involved in educating and precepting students (Coffman & Wong, 1997). Conclusion

This study addressed the issue of what NP program directors currently emphasize and ideally want to emphasize in their curricula. It may be argued that all topics represent positive curriculum changes for primary care NP education, with perhaps one exception ("tertiary/quaternary care"). However, the findings suggest clear differences. The NP program directors, for example, are more in favor of increasing the emphasis on "business management of practice," "use of electronic information systems," and "health care economics and financing" than on "patient teachingeducation," "outpatient/ambulatory care," and "psychosocial care," for which they already rate themselves high for current emphasis. Furthermore, the study shows an excellent level of fit between the needs of the emerging health care system and where the NP program directors believe their programs to be as well as where they would like to be going. This understanding and movement by NP leaders bodes well for the strategic future of advanced practice nursing. As the changing health care system grows more sophisticated in articulating what it wants and needs from health care professionals, it may quite likely find that NPs and NP education programs are already there.

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BELLACK ET AL

The barriers to change do not present as encouraging a picture, however. Graduate nursing education has never benefited from the enormous federal support that flows to graduate medical education. The resulting need for NP education programs to be market-responsive may explain why they find themselves more in line with changing health care realities than their physician colleagues. As NP educators attempt to respond to changing demands from the health care delivery system, they find themselves with constrained finances and overburdened curricula. It seems unlikely that the patterns of funding will change, although some proposals are being considered. It seems even less likely that the basic allocation of federal funds to advanced NP education will change. To address both problems--an already crowded curriculum and inadequate funding--will require creativity and resourcefulness. Some suggestions from the authors may be in order.

Now may be the time to aggressively pursue a true lifelong approach to nursing education and professionalism.

Now may be the time to aggressively pursue a true lifelong approach to nursing education and professionalism. At the advanced practice level, is it possible to restructure NP practitioner education for minimal competence at a beginning advanced practice level, with a consequent shifting toward a shared responsibility for lifelong learning, in collaboration with organized health care systems and the employers of NPs? Can the new information and communication technologies assist in this restructuring, thereby freeing up

more curriculum time and, perhaps even more importantly, faculty time for the required practice and research endeavors? Can partnerships with managed care organizations be created in a way to enlarge the learning space, number of faculty, and clinical learning experiences of students while maintaining the quality of the educational program? Finally, are similar challenges now being addressed by other professional education programs, and might NP programs join with them to create common solutions that are both more effective and less expensive in producing desired outcomes? Such creative options exist and could be seized as opportunities for responding in entirely new ways to the ever-increasing demands and constraints that challenge advanced NP education. In summary, the NP program directors are wellacquainted with the day to day realities of NP education and with the increasing demands on their programs to ensure adequate learning experiences for their students as well as the several barriers to doing so. Clearly, NP program directors are in a key position, both individually and collectively, to directly influence and shape NP curricula. Given the increasing demand and acceptance by the public, and by public and private insurers for primary care advanced practice nurses (Freudenheim, 1997), there is every reason to hope that innovative solutions and adequate resources will be found by programs and funders alike to reduce or overcome the identified barriers to needed curricular change. Such a response is necessary to expand the learning environment to the benefit of both nursing education and practice, which will ultimately benefit the consumers of nursing and health care.

Acknowledgment The authors gratefully acknowledge the research support activities of Dyian Holmes and Marcia Higaki, both of the Medical University of South Carolina, Charleston, SC.

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