- Email: [email protected]
Doctor of Nursing Practice Curricula Redesign: Challenge, Change and Collaboration
BY FACULTY FOR FACULTY
Doctor of Nursing Practice Curricula Redesign: Challenge, Change and Collaboration Sandy Carollo, PhD, FNP-BC, and Anne Mason, DNP, PMHNP-BC ABSTRACT
Changes in health care, including an increasingly complex health care delivery system, require advanced practice nurses to lead the charge toward meeting the triple aim target of improved cost-effective, patientcentered care. Nurse educators are challenged with developing curricula that meet national core competencies while addressing leadership, policy, and compassionate care skills. This article presents 1 university’s experience with curriculum revision including assessment, collaboration, and transition with application to both the redesign process and curricular outcomes. Keywords: delivery of health care, nurse educators, nurse practitioners, teaching Ó 2016 Elsevier Inc. All rights reserved.
H
igh-quality, cost-effective health care delivery and the preparation of advanced practice registered nurses (APRNs) to serve as leaders in affecting change have fueled curricula review and redesign in many educational institutions. The Institute of Medicine1 published a detailed report in 2011 titled The Future of Nursing: Leading Change, Advancing Health in which APRNs are noted as key contributors to reaching the triple aim2 (improve population health, improve individual health, and reduce cost per capita) of health care reform. The challenge faced by nurse educators is to lead and evaluate APRN students toward meeting nationally recognized competencies,3 with a focus on the triple aim.4 Additionally, nurse educators are charged to develop expert nurse clinicians within their specific discipline who have an inherent drive for lifelong learning.3 This includes paying attention to knowledge and clinical skill acquisition and role development, all of which promote transition to practice with the fullest extent of these competencies. These APRNs are prepared to meet the demands of a complex health care environment. The strength of nurse practitioner (NP) clinical judgment may be attributed in part to the quality of education and training accessed in formative preparation before entering the workforce. As such, it lies on the shoulders of educators to review the process by www.npjournal.org
which workforce demands may be met.1 With the need for APRNs growing, it is imperative that academic preparation be current and include content aligning with the triple aim2,4 of highlighting safe, competent, and cost-effective care for individuals and communities. This belief is supported by Earnest and Brandt,4 who offered for health care and education systems to create the “triple aim for alignment,” the way forward is together. Health systems and educators need to develop a common understanding of transformation and reform, define new workforce competencies and the educational resources needed to meet them, and repurpose existing resources to meet shared goals.4(p499) With the dissemination of the 2013 populationfocused NP competencies of the National Organization of Nurse Practitioner Faculty (NONPF),3 the 2006 American Association of Colleges of Nursing (AACN) Essentials of Doctoral Education for Advanced Nursing Practice,5 and the 2015 AACN white paper The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations-Report from the Task Force on the Implementation of the DNP,6 NP programs are identifying curricular gaps in providing vital education to achieving competencies. Achieving competencies requires collaboration between leadership at the academic and clinical practice levels. Innovative and enhanced learning methods, The Journal for Nurse Practitioners - JNP
e1
including the use of emerging technologies, facilitate knowledge and skill acquisition and promote clinical expertise.7 A primary recommendation of The Future of Nursing: Leading Change, Advancing Health Institute of Medicine report1 is the ability of NPs to practice to the fullest extent of their education and training. Our current complex health care environment provides a compelling argument for effective and well-trained clinicians. The purpose of this article is to describe the processes used by 2 DNP NP programs (family [FNP] and psychiatric mental health [PMHNP]) in a research-intensive university to redesign their respective curricula based on the new 2013 NONPF competencies3 and AACN DNP essentials,5 including the development of shared learning opportunities. Descriptions of future work and expected implementation challenges will be provided. Additionally, disseminating this information will contribute to a thin body of knowledge on competency-based curriculum design.8 COMMITMENT
A commitment to align the triple aim2,4 and the health care education system requires a closer evaluation of where we currently stand. A complex and rapidly developing health care system beckons curricular reform that aligns with market need. To prepare advanced practice nursing students to meet the needs of the health care market, pedagogical approaches must consider not only the knowledge and skills necessary but also critical reasoning, data access and application, policy and governance, and team-based care approaches to clinical problem solving in preparing students to meet clinical environmental changes. Attention to these changes constitutes a commitment to meeting the needs of a broad stakeholder pool including students, faculty, community partners, and consumers. One approach to addressing this commitment is consideration of transition to a competency model of teaching and learning. Although competency has yet to achieve a clear definition in nursing,9 there is a commonly accepted point and that is to ensure nurses have the knowledge, skills, and abilities expected and required for their practice settings.10 Several important e2
The Journal for Nurse Practitioners - JNP
elements are incorporated in competency-based learning including collaboration among and between stakeholders. It is essential that teaching-learning institutions move toward meeting the needs of a complex and changing work environment through the identification of outcomes for initial and progressive evaluation of competency specific to the discipline. This should occur at scheduled intervals through assessments using a variety of approaches and distributed throughout the learning process.10,11 CHANGE
The change process used at this university for curriculum evaluation and redesign was a multifaceted approach using an iterative process with multiple stakeholders to achieve a highly informed curriculum. The lead faculty for each of the NP tracks began curriculum evaluation during participation in the self-study preparation for reaccreditation by the Commission of Collegiate Nursing Education. Engagement with the College of Nursing leadership team was the initial step to securing support for robust curriculum assessment followed by ongoing discussions with program-specific faculty. NONPF Population-Focused Competencies3 and AACN Essentials of Doctoral Education for Advanced Nursing Practice5 served as the basis for comparing courses and determining outcomes. Peer faculty from each program conducted gap analysis and redefined the curricula with attention directed toward stakeholder input and review of the mission, vision, and values of the college and institution. Programspecific curriculum retreats were held separately and were attended by the majority of the faculty that teach in each of the NP specialties, the respective program lead faculty, and the DNP director. A Strengths, Weaknesses, Opportunities, and Threats analysis framed the discussion of the curriculum and was used to conceptualize curriculum changes. Each retreat occurred over a 2-day period and ended with a complete outline of the expected curriculum changes. The lead faculty of the NP programs shared with one another the proposed curricula and the identified gaps to detect opportunities for collaboration across programs. This iterative curriculum assessment process was completed over a 3-month period, which offered the opportunity to review Volume
-,
Issue
-, -/-
2016
documents in detail, discuss the level of priority of needs or changes, and propose plans for changes. With a goal of alignment with the triple aim,2,4 several key activities were identified as necessary to achieve a successful and collective redesign process including assessment, communication, collaboration, and transition. Assessment
One major curriculum theme that was identified in the assessment process as challenging for both curricula was the application of across the life span considerations in courses. The FNP program had maintained age-focused course work, whereas the PMHNP program had maintained a limited application of age-focused courses. One major change for the FNP program included transitioning from population-focused clinical courses to life span focus moving away from adult/elder, pediatrics, and women’s health to health maintenance, acute conditions, and chronic conditions with select cases across the life span highlighted in each course. For the PMHNP program, it was identified through the gap analysis that pediatrics content had been applied inconsistently through courses. Course content was remodeled to meet the new competencies and to reflect current practice models, including, in keeping with the triple aim,2,4 issues focused on fiduciary responsibilities. Another major theme identified in the assessment process was difficulty evaluating student achievement in courses that combined clinical and didactic experiences. The separation of courses allows grading of each component (ie, theoretical knowledge independently from practical application of knowledge). Furthermore, this approach allows evaluative measures that are specific and sensitive to assessing students in these different learning environments. In the PMHNP program, these changes occurred primarily in the psychotherapy-focused courses, which moved from 2 independent individual and group therapy courses with clinical embedded in the course requirements to 2 didactic courses focusing on introduction, competency, and then mastery of psychotherapeutic interventions (individual, group, and family) and a separate clinical course for active practice in conducting individual and group therapy. This www.npjournal.org
change better reflects the role of the PMHNP in practice and exemplifies some of the feedback from community stakeholders. For the FNP program, this resulted in 3 core clinical courses transforming to 6 courses; each core course consisted of a pairing of 2 courses, a didactic course and a separate clinical course. Both programs identified the need to implement pree and posteobjective structured clinical examinations (OSCEs) as a tool to assess readiness for advanced practice clinical and evaluation of clinical achievement. The triple aim2,4 charges academe to produce graduates who are safe, competent, and fiscally responsible. To meet this, faculty explored student evaluation options and agreed to embed OSCEs in the new curricula. The OSCE approach to the evaluation of clinical skills has been used by medical schools for over 40 years and more recently to assess advanced practice nursing student competencies.11,12 Through this process, students will demonstrate competencies through the application of critical analysis and clinical skills to a given scenario or task. Students will receive focused feedback of predetermined clinical tasks based on benchmarks noted in the syllabi. Additionally, students will maintain a self-reflection journal throughout the clinical courses and will apply course and personal objectives to learned experiences in the clinical setting as well as the pre- and post-OSCEs. The preclinical OSCE will serve as an opportunity for students to practice self-awareness of strengths, needs, and professional comportment. A postclinical OSCE will serve as a competency experience. Through assessment, course content was remodeled to meet the new population-focused competencies and to reflect current practice models. Additionally, faculty identified expected outcomes of student evaluation including knowledge, inquiry, clinical skills, professionalism/role development, communication/collaboration, systems, and continuous improvement through reflection. These domains will provide the framework for formative evaluations of student performance. Communication
Consistent, open communication was identified early as a vital element in achieving alignment with the The Journal for Nurse Practitioners - JNP
e3
triple aim2,4 and was essential throughout the redesign process. Monthly track-specific faculty meetings provided insight and direction for the new curricula. Lead faculty in each program met monthly with College of Nursing leadership to discuss the redesign progress, challenges, and barriers. Additional direction was solicited and received from students and community practice partners. In addition to serving as a key activity in the redesign process, communication was further identified as a central component to optimizing successful student preparation for clinical practice. Effective communication was noted in 2008 as a national patient safety goal by the Joint Commission.13 Therefore, the redesign process included opportunities to promote patient safety and to enhance understanding and performance of professional communication skills, including intentional targeting of key areas to allow practice opportunities for students. Course redesign included the use of discussion forums, interprofessional simulation, and the use of standardized models for reporting and consultation including ongoing use of the Situation, Background, Assessment, and Recommendation13 technique. Additional exercises include the expanded use of electronic medical records; dictation; Subjective, Objective, Assessment, Plan documentation of comprehensive and focused charting; and the use of electronic resources for access to evidence-based protocols. Students enrolled in the DNP program (all tracks) are required to attend on-campus dates together as a large group at least twice a year. At these mandatory on-campus dates, students will engage in networking and interdisciplinary presentations from industry leaders including topics focused on clinical practice, practice development, and policy. Simulation will also be offered at this time, providing a hands-on virtual clinical experience using a mannequin followed by debriefing or guided reflection.14 This experience will allow small groups of 4 to 5 students to engage in a predetermined clinical scenario for 15 minutes and then debrief on their experience, focusing on strengths and areas for improvement. Four domains have been identified by faculty as fundamental to ongoing communication and specifically to the importance of this area in the e4
The Journal for Nurse Practitioners - JNP
curricula, including patient-centered care, evidencebased practice, informatics, and teamwork. Collaboration
The ability to positively impact the health of individuals and communities and to do so at a reduced cost will require significant collaboration. Concerns of educational institutions and faculty for APRN programs are considerable. The AACN white paper on the current state of clinical education15 outlines increased demands for APRN education, national faculty shortages, and adequacy of clinical sites and preceptors as national issues. During curricular redesign, concerns were consistent including financial/budgetary constraints, faculty availability, and physical environment limitations. In the curricular redesign process, collaboration was identified as the key to meeting these challenges. The growing faculty shortage and competitive environment for clinical sites and preceptors highlight the importance of collaboration internally between educational tracks to support mutual content when appropriate. In addition, collaboration externally with practice partners invites consideration of innovative strategies to meet the needs of students and faculty such as shared employment for faculty practice plans. Moreover, the national call for interprofessional learning opportunities, case-based learning, simulation, and community service opportunities further invites faculty to have ongoing collaborative opportunities. The DNP program includes several core courses shared by multiple tracks including FNP, PMHNP, population health, and post-master’s DNP students. In reviewing collaborative opportunities for the FNP and PMHNP programs, track lead faculty examined similarities in course content and outcomes to identify areas in which both tracks could engage together in a single learning opportunity. This included interprofessional education activities embedded in the clinical courses that include participation in a discussion board to identify common threads and shared knowledge and participation in simulation. Considering collaboration, 2 domains emerged as essential to both the redesign process and successful transition to practice: connection and common understanding. Volume
-,
Issue
-, -/-
2016
Ongoing collaboration was essential in the final stretch of the redesign process. With new curricula sketched out, further analyses of the needs of learning experiences for clinical competency were identified. One major consideration during this evaluation was analyzing the number of clinical hours and types of clinical experiences essential in NP preparation. Included in these conversations were discussions about the number of clinical hours required for certification to achieve minimum competency in practice and the number of hours deemed necessary to complete the DNP project at the end of each program. This process was accomplished over another 3-month period, ending with a review of the rough draft of proposed changes by the program director and consultation by an instructional design specialist. The final, major step in rewriting the NP curricula was generation of the syllabi representing the proposed courses. In each track, attention was focused on the need to better represent across the life span concepts noted in the consensus model and
required for certification. The syllabi were initially written by the lead faculty member in each program and then reviewed by other faculty who conducted peer review to assess for missing elements and complete edits. Syllabi were further reviewed by 2 lead administrators familiar with the proposed curricula. Syllabi were refined through periodic meetings over a 3-month period. The final step in syllabi preparation was a review by the DNP program director to ensure all syllabi would meet the graduate school and university standards. After meeting these expectations, the syllabi bundle was presented to the CON graduate curriculum committee for review in its entirety and, with approval, was submitted to the university for official review and progression toward acceptance for implementation (Figure). Transition
The official review of syllabi occurred over a 1-year time frame, and the DNP program is ready to transition to the new curricula. Moving forward, it has
Figure. An overview description and time line for these events.
www.npjournal.org
The Journal for Nurse Practitioners - JNP
e5
been important to remember our original undertaking; to meet the charge of the triple aim,2,4 3 areas of focus must be addressed: 1) enhanced patient care quality, 2) enhanced population health, and 3) reduction in per capita health care costs. To address this call, our students will engage in systems thinking, an approach that encourages thinking beyond the single situation to one that examines preceding events impacting individuals and populations. This approach focuses on several domains including patientcentered care, evidence-based practice, teamwork and collaboration, safety, quality improvement, and informatics. This intentional approach toward systems thinking will not only address the goals set forth with the triple aim2,4 but also move students closer to meeting competencies.16 The concept of competency in nursing includes an environment that supports practice-focused learning opportunities, student engagement and accountability in assessment, and teaching/learning that is personalized to meet individual needs.9 The new curricula for this university included a change in mind-set to envision movement from the traditional didactic model toward a competency-based model of teaching and learning with the application of across the life span concepts threaded throughout. For the PMHNP program, this included transition to more intentional pediatric content and revision of clinical courses to reflect identified learning outcomes in the form of introduction, competency, and mastery of the expected APRN skills. For the FNP program, this included separating the 3 population-focused core clinical courses and replacing these with a life span approach starting with health maintenance followed by acute care then chronic care and with practicum courses taken in tandem and graded separately. To further enhance the competency approach, a flipped classroom17 method is encouraged for the didactic courses with student learners preparing in advance for in-class dialogue and engagement in clinical case studies or other class time activities. The flipped classroom methodology places the responsibility of preparation for class engagement on the student and uses seat time for active learning engagement.17 This supports improvement in practice-focused learning, student engagement, and e6
The Journal for Nurse Practitioners - JNP
accountability. For the internship courses, students will engage in seminar/classroom time in addition to required clinical rotation hours. They will engage in discussion boards, reflective journaling, and group presentation activities, all of which provide additional opportunity to enhance role development and further discussion of practice planning. CLOSURE
Curriculum redesign was initiated as a perfect storm of events unfolded including Commission of Collegiate Nursing Education preparation and reaccreditation, changes in leadership of the individual NP programs, and release of the new NONPF Population-Focuses Competencies. These events afforded ample opportunity to map the program outcomes to the competencies, the Essentials of Doctoral Education for Advanced Nursing Practice, and the program outcomes that fostered discussions within and across the NP tracks. These discussions identified strategies for collaborative opportunities and sharing resources. Additionally, reanalyzing and increasing clinical expectations resulted in further efforts for enhanced student preparation for clinical practice and enhanced relationships with practice partners and may result in a larger impact to serve diverse and rural settings. Program faculty and leadership continue to refine plans of study, scheduling the transition between new and old curricula while maintaining acceptable enrollment across programs, and meet student needs for courses. The support of community stakeholders, including clinical agencies and preceptors, includes not only deep appreciation for their contribution to the development of the new curricula but also ongoing dialogue about requirements and potential changes in foci of the students in their settings with the planned changes. CONCLUSIONS
Independent yet complementary curriculum evaluation and redesign are achievable with intentional activities and accurately providing the necessary time for assessment, communication, collaboration, and transition. This complex and sometimes simultaneous process allowed 2 NP programs to consider and develop opportunities for shared learning events as Volume
-,
Issue
-, -/-
2016
well as enhanced clinical requirements. Issues such as scheduling, staffing, implementing, and assessing outcomes are expected but with a cohesive approach from the beginning can be mitigated. This endeavor of shared understanding and common goals supports student growth beyond core competencies and allows for optimal clinical practice. Finally, this effort provides a foundation for developing clinicians who are systems thinkers prepared to improve the health of individuals and communities while maintaining cost-effective health care, open to change, and poised to positively impact outcomes. References 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Retrieved from http://books.nap.edu/openbook.php?record_ id¼12956&page¼R1. 2011. Accessed August 2, 2016. 2. Berwick D, Nolan T, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. 3. National Organization of Nurse Practitioner Faculties. Population-focused nurse practitioner competencies. http://www.nonpf.org/resource/resmgr/ Competencies/CompilationPopFocusComps2013.pdf. 2013. Accessed August 8, 2016. 4. Earnest M, Brandt B. Aligning practice redesign and interprofessional education to advance triple aim outcomes. J Interprof Care. 2014;28(6):497-500. 5. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. http://www.aacn.nche.edu/dnp/ pdf/essentials.pdf. 2006. Accessed August 8, 2016. 6. American Association of Colleges of Nursing. The doctor of nursing practice: current issues and clarifying recommendations-report from the task force on the implementation of the DNP. Retrieved from http://www.aacn.nche.edu/ aacn publications/white-papers/DNP-Implementation-TF-Report-8-15.pdf. 2015. Accessed August 10, 2016. 7. Huston C. The impact of emerging technology on nursing care: warp speed ahead. Online J Issues Nurs. 2013;18(2):1. 8. LeCuyer E, DeSocio J, Brody M, Schlick R, Menkens R. From objectives to competencies: operationalizing the NONPF PMHNP competencies for use in a graduate curriculum. Arch Psychiatr Nurs. 2009;23:185-199.
www.npjournal.org
9. Tilley D. Competency in nursing: a concept analysis. J Contin Educ Nurs. 2008;39(2):58-64. 10. Anema M, McCoy J. Competency Based Nursing Education: Guide to Achieving Outstanding Learner Outcomes. New York, NY: Springer Publishing; 2010. 11. Richardson L, Resick L, Leonardo M, Pearsall C. Undergraduate students as standardized patients to assess advanced practice nursing student competencies. Nurs Educ. 2009;34(1):12-16. 12. Clark C. Evaluating nurse practitioner students through objective structured clinical examination. Nurs Educ Perspect. 2015;36(1):53-54. 13. Dunsforth J. Structured communication: improving patient safety with SBAR. Nurs Womens Health. 2009;13(5):384-390. 14. Shinnick M, Woo M, Horwich T, Steadman R. Debriefing: the most important component of simulation? Clin Simul Nurs. 2011;7:e105-e111. 15. American Association of Colleges of Nursing. White paper: current state of APRN clinical education. http://www.aacn.nche.edu/APRN-white-paper.pdf. 2105. Accessed August 10, 2016. 16. Dolansky MA, Moore SM. Quality and safety education for nurses (QSEN): the key is systems thinking. Online J Issues Nurs. 2013;18(3):1. 17. McLaughlin J, Roth M, Glatt D, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014;89(2):236-243.
Sandy Carollo, PhD, MSN, FNP-BC, is a Clinical Associate Professor, Associate Dean/Academic Director and FNP Track Coordinator at Washington State University College of Nursing in Yakima, WA, and can be reached at scarollo@ wsu.edu. Anne Mason, DNP, PMHNP-BC, is the DNP Program Director & PMHNP Track Coordinator at Washington State University College of Nursing in Spokane, WA. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.11.011
The Journal for Nurse Practitioners - JNP
e7
Doctor of Nursing Practice Curricula Redesign: Challenge, Change and Collaboration Sandy Carollo, PhD, FNP-BC, and Anne Mason, DNP, PMHNP-BC ABSTRACT
Changes in health care, including an increasingly complex health care delivery system, require advanced practice nurses to lead the charge toward meeting the triple aim target of improved cost-effective, patientcentered care. Nurse educators are challenged with developing curricula that meet national core competencies while addressing leadership, policy, and compassionate care skills. This article presents 1 university’s experience with curriculum revision including assessment, collaboration, and transition with application to both the redesign process and curricular outcomes. Keywords: delivery of health care, nurse educators, nurse practitioners, teaching Ó 2016 Elsevier Inc. All rights reserved.
H
igh-quality, cost-effective health care delivery and the preparation of advanced practice registered nurses (APRNs) to serve as leaders in affecting change have fueled curricula review and redesign in many educational institutions. The Institute of Medicine1 published a detailed report in 2011 titled The Future of Nursing: Leading Change, Advancing Health in which APRNs are noted as key contributors to reaching the triple aim2 (improve population health, improve individual health, and reduce cost per capita) of health care reform. The challenge faced by nurse educators is to lead and evaluate APRN students toward meeting nationally recognized competencies,3 with a focus on the triple aim.4 Additionally, nurse educators are charged to develop expert nurse clinicians within their specific discipline who have an inherent drive for lifelong learning.3 This includes paying attention to knowledge and clinical skill acquisition and role development, all of which promote transition to practice with the fullest extent of these competencies. These APRNs are prepared to meet the demands of a complex health care environment. The strength of nurse practitioner (NP) clinical judgment may be attributed in part to the quality of education and training accessed in formative preparation before entering the workforce. As such, it lies on the shoulders of educators to review the process by www.npjournal.org
which workforce demands may be met.1 With the need for APRNs growing, it is imperative that academic preparation be current and include content aligning with the triple aim2,4 of highlighting safe, competent, and cost-effective care for individuals and communities. This belief is supported by Earnest and Brandt,4 who offered for health care and education systems to create the “triple aim for alignment,” the way forward is together. Health systems and educators need to develop a common understanding of transformation and reform, define new workforce competencies and the educational resources needed to meet them, and repurpose existing resources to meet shared goals.4(p499) With the dissemination of the 2013 populationfocused NP competencies of the National Organization of Nurse Practitioner Faculty (NONPF),3 the 2006 American Association of Colleges of Nursing (AACN) Essentials of Doctoral Education for Advanced Nursing Practice,5 and the 2015 AACN white paper The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations-Report from the Task Force on the Implementation of the DNP,6 NP programs are identifying curricular gaps in providing vital education to achieving competencies. Achieving competencies requires collaboration between leadership at the academic and clinical practice levels. Innovative and enhanced learning methods, The Journal for Nurse Practitioners - JNP
e1
including the use of emerging technologies, facilitate knowledge and skill acquisition and promote clinical expertise.7 A primary recommendation of The Future of Nursing: Leading Change, Advancing Health Institute of Medicine report1 is the ability of NPs to practice to the fullest extent of their education and training. Our current complex health care environment provides a compelling argument for effective and well-trained clinicians. The purpose of this article is to describe the processes used by 2 DNP NP programs (family [FNP] and psychiatric mental health [PMHNP]) in a research-intensive university to redesign their respective curricula based on the new 2013 NONPF competencies3 and AACN DNP essentials,5 including the development of shared learning opportunities. Descriptions of future work and expected implementation challenges will be provided. Additionally, disseminating this information will contribute to a thin body of knowledge on competency-based curriculum design.8 COMMITMENT
A commitment to align the triple aim2,4 and the health care education system requires a closer evaluation of where we currently stand. A complex and rapidly developing health care system beckons curricular reform that aligns with market need. To prepare advanced practice nursing students to meet the needs of the health care market, pedagogical approaches must consider not only the knowledge and skills necessary but also critical reasoning, data access and application, policy and governance, and team-based care approaches to clinical problem solving in preparing students to meet clinical environmental changes. Attention to these changes constitutes a commitment to meeting the needs of a broad stakeholder pool including students, faculty, community partners, and consumers. One approach to addressing this commitment is consideration of transition to a competency model of teaching and learning. Although competency has yet to achieve a clear definition in nursing,9 there is a commonly accepted point and that is to ensure nurses have the knowledge, skills, and abilities expected and required for their practice settings.10 Several important e2
The Journal for Nurse Practitioners - JNP
elements are incorporated in competency-based learning including collaboration among and between stakeholders. It is essential that teaching-learning institutions move toward meeting the needs of a complex and changing work environment through the identification of outcomes for initial and progressive evaluation of competency specific to the discipline. This should occur at scheduled intervals through assessments using a variety of approaches and distributed throughout the learning process.10,11 CHANGE
The change process used at this university for curriculum evaluation and redesign was a multifaceted approach using an iterative process with multiple stakeholders to achieve a highly informed curriculum. The lead faculty for each of the NP tracks began curriculum evaluation during participation in the self-study preparation for reaccreditation by the Commission of Collegiate Nursing Education. Engagement with the College of Nursing leadership team was the initial step to securing support for robust curriculum assessment followed by ongoing discussions with program-specific faculty. NONPF Population-Focused Competencies3 and AACN Essentials of Doctoral Education for Advanced Nursing Practice5 served as the basis for comparing courses and determining outcomes. Peer faculty from each program conducted gap analysis and redefined the curricula with attention directed toward stakeholder input and review of the mission, vision, and values of the college and institution. Programspecific curriculum retreats were held separately and were attended by the majority of the faculty that teach in each of the NP specialties, the respective program lead faculty, and the DNP director. A Strengths, Weaknesses, Opportunities, and Threats analysis framed the discussion of the curriculum and was used to conceptualize curriculum changes. Each retreat occurred over a 2-day period and ended with a complete outline of the expected curriculum changes. The lead faculty of the NP programs shared with one another the proposed curricula and the identified gaps to detect opportunities for collaboration across programs. This iterative curriculum assessment process was completed over a 3-month period, which offered the opportunity to review Volume
-,
Issue
-, -/-
2016
documents in detail, discuss the level of priority of needs or changes, and propose plans for changes. With a goal of alignment with the triple aim,2,4 several key activities were identified as necessary to achieve a successful and collective redesign process including assessment, communication, collaboration, and transition. Assessment
One major curriculum theme that was identified in the assessment process as challenging for both curricula was the application of across the life span considerations in courses. The FNP program had maintained age-focused course work, whereas the PMHNP program had maintained a limited application of age-focused courses. One major change for the FNP program included transitioning from population-focused clinical courses to life span focus moving away from adult/elder, pediatrics, and women’s health to health maintenance, acute conditions, and chronic conditions with select cases across the life span highlighted in each course. For the PMHNP program, it was identified through the gap analysis that pediatrics content had been applied inconsistently through courses. Course content was remodeled to meet the new competencies and to reflect current practice models, including, in keeping with the triple aim,2,4 issues focused on fiduciary responsibilities. Another major theme identified in the assessment process was difficulty evaluating student achievement in courses that combined clinical and didactic experiences. The separation of courses allows grading of each component (ie, theoretical knowledge independently from practical application of knowledge). Furthermore, this approach allows evaluative measures that are specific and sensitive to assessing students in these different learning environments. In the PMHNP program, these changes occurred primarily in the psychotherapy-focused courses, which moved from 2 independent individual and group therapy courses with clinical embedded in the course requirements to 2 didactic courses focusing on introduction, competency, and then mastery of psychotherapeutic interventions (individual, group, and family) and a separate clinical course for active practice in conducting individual and group therapy. This www.npjournal.org
change better reflects the role of the PMHNP in practice and exemplifies some of the feedback from community stakeholders. For the FNP program, this resulted in 3 core clinical courses transforming to 6 courses; each core course consisted of a pairing of 2 courses, a didactic course and a separate clinical course. Both programs identified the need to implement pree and posteobjective structured clinical examinations (OSCEs) as a tool to assess readiness for advanced practice clinical and evaluation of clinical achievement. The triple aim2,4 charges academe to produce graduates who are safe, competent, and fiscally responsible. To meet this, faculty explored student evaluation options and agreed to embed OSCEs in the new curricula. The OSCE approach to the evaluation of clinical skills has been used by medical schools for over 40 years and more recently to assess advanced practice nursing student competencies.11,12 Through this process, students will demonstrate competencies through the application of critical analysis and clinical skills to a given scenario or task. Students will receive focused feedback of predetermined clinical tasks based on benchmarks noted in the syllabi. Additionally, students will maintain a self-reflection journal throughout the clinical courses and will apply course and personal objectives to learned experiences in the clinical setting as well as the pre- and post-OSCEs. The preclinical OSCE will serve as an opportunity for students to practice self-awareness of strengths, needs, and professional comportment. A postclinical OSCE will serve as a competency experience. Through assessment, course content was remodeled to meet the new population-focused competencies and to reflect current practice models. Additionally, faculty identified expected outcomes of student evaluation including knowledge, inquiry, clinical skills, professionalism/role development, communication/collaboration, systems, and continuous improvement through reflection. These domains will provide the framework for formative evaluations of student performance. Communication
Consistent, open communication was identified early as a vital element in achieving alignment with the The Journal for Nurse Practitioners - JNP
e3
triple aim2,4 and was essential throughout the redesign process. Monthly track-specific faculty meetings provided insight and direction for the new curricula. Lead faculty in each program met monthly with College of Nursing leadership to discuss the redesign progress, challenges, and barriers. Additional direction was solicited and received from students and community practice partners. In addition to serving as a key activity in the redesign process, communication was further identified as a central component to optimizing successful student preparation for clinical practice. Effective communication was noted in 2008 as a national patient safety goal by the Joint Commission.13 Therefore, the redesign process included opportunities to promote patient safety and to enhance understanding and performance of professional communication skills, including intentional targeting of key areas to allow practice opportunities for students. Course redesign included the use of discussion forums, interprofessional simulation, and the use of standardized models for reporting and consultation including ongoing use of the Situation, Background, Assessment, and Recommendation13 technique. Additional exercises include the expanded use of electronic medical records; dictation; Subjective, Objective, Assessment, Plan documentation of comprehensive and focused charting; and the use of electronic resources for access to evidence-based protocols. Students enrolled in the DNP program (all tracks) are required to attend on-campus dates together as a large group at least twice a year. At these mandatory on-campus dates, students will engage in networking and interdisciplinary presentations from industry leaders including topics focused on clinical practice, practice development, and policy. Simulation will also be offered at this time, providing a hands-on virtual clinical experience using a mannequin followed by debriefing or guided reflection.14 This experience will allow small groups of 4 to 5 students to engage in a predetermined clinical scenario for 15 minutes and then debrief on their experience, focusing on strengths and areas for improvement. Four domains have been identified by faculty as fundamental to ongoing communication and specifically to the importance of this area in the e4
The Journal for Nurse Practitioners - JNP
curricula, including patient-centered care, evidencebased practice, informatics, and teamwork. Collaboration
The ability to positively impact the health of individuals and communities and to do so at a reduced cost will require significant collaboration. Concerns of educational institutions and faculty for APRN programs are considerable. The AACN white paper on the current state of clinical education15 outlines increased demands for APRN education, national faculty shortages, and adequacy of clinical sites and preceptors as national issues. During curricular redesign, concerns were consistent including financial/budgetary constraints, faculty availability, and physical environment limitations. In the curricular redesign process, collaboration was identified as the key to meeting these challenges. The growing faculty shortage and competitive environment for clinical sites and preceptors highlight the importance of collaboration internally between educational tracks to support mutual content when appropriate. In addition, collaboration externally with practice partners invites consideration of innovative strategies to meet the needs of students and faculty such as shared employment for faculty practice plans. Moreover, the national call for interprofessional learning opportunities, case-based learning, simulation, and community service opportunities further invites faculty to have ongoing collaborative opportunities. The DNP program includes several core courses shared by multiple tracks including FNP, PMHNP, population health, and post-master’s DNP students. In reviewing collaborative opportunities for the FNP and PMHNP programs, track lead faculty examined similarities in course content and outcomes to identify areas in which both tracks could engage together in a single learning opportunity. This included interprofessional education activities embedded in the clinical courses that include participation in a discussion board to identify common threads and shared knowledge and participation in simulation. Considering collaboration, 2 domains emerged as essential to both the redesign process and successful transition to practice: connection and common understanding. Volume
-,
Issue
-, -/-
2016
Ongoing collaboration was essential in the final stretch of the redesign process. With new curricula sketched out, further analyses of the needs of learning experiences for clinical competency were identified. One major consideration during this evaluation was analyzing the number of clinical hours and types of clinical experiences essential in NP preparation. Included in these conversations were discussions about the number of clinical hours required for certification to achieve minimum competency in practice and the number of hours deemed necessary to complete the DNP project at the end of each program. This process was accomplished over another 3-month period, ending with a review of the rough draft of proposed changes by the program director and consultation by an instructional design specialist. The final, major step in rewriting the NP curricula was generation of the syllabi representing the proposed courses. In each track, attention was focused on the need to better represent across the life span concepts noted in the consensus model and
required for certification. The syllabi were initially written by the lead faculty member in each program and then reviewed by other faculty who conducted peer review to assess for missing elements and complete edits. Syllabi were further reviewed by 2 lead administrators familiar with the proposed curricula. Syllabi were refined through periodic meetings over a 3-month period. The final step in syllabi preparation was a review by the DNP program director to ensure all syllabi would meet the graduate school and university standards. After meeting these expectations, the syllabi bundle was presented to the CON graduate curriculum committee for review in its entirety and, with approval, was submitted to the university for official review and progression toward acceptance for implementation (Figure). Transition
The official review of syllabi occurred over a 1-year time frame, and the DNP program is ready to transition to the new curricula. Moving forward, it has
Figure. An overview description and time line for these events.
www.npjournal.org
The Journal for Nurse Practitioners - JNP
e5
been important to remember our original undertaking; to meet the charge of the triple aim,2,4 3 areas of focus must be addressed: 1) enhanced patient care quality, 2) enhanced population health, and 3) reduction in per capita health care costs. To address this call, our students will engage in systems thinking, an approach that encourages thinking beyond the single situation to one that examines preceding events impacting individuals and populations. This approach focuses on several domains including patientcentered care, evidence-based practice, teamwork and collaboration, safety, quality improvement, and informatics. This intentional approach toward systems thinking will not only address the goals set forth with the triple aim2,4 but also move students closer to meeting competencies.16 The concept of competency in nursing includes an environment that supports practice-focused learning opportunities, student engagement and accountability in assessment, and teaching/learning that is personalized to meet individual needs.9 The new curricula for this university included a change in mind-set to envision movement from the traditional didactic model toward a competency-based model of teaching and learning with the application of across the life span concepts threaded throughout. For the PMHNP program, this included transition to more intentional pediatric content and revision of clinical courses to reflect identified learning outcomes in the form of introduction, competency, and mastery of the expected APRN skills. For the FNP program, this included separating the 3 population-focused core clinical courses and replacing these with a life span approach starting with health maintenance followed by acute care then chronic care and with practicum courses taken in tandem and graded separately. To further enhance the competency approach, a flipped classroom17 method is encouraged for the didactic courses with student learners preparing in advance for in-class dialogue and engagement in clinical case studies or other class time activities. The flipped classroom methodology places the responsibility of preparation for class engagement on the student and uses seat time for active learning engagement.17 This supports improvement in practice-focused learning, student engagement, and e6
The Journal for Nurse Practitioners - JNP
accountability. For the internship courses, students will engage in seminar/classroom time in addition to required clinical rotation hours. They will engage in discussion boards, reflective journaling, and group presentation activities, all of which provide additional opportunity to enhance role development and further discussion of practice planning. CLOSURE
Curriculum redesign was initiated as a perfect storm of events unfolded including Commission of Collegiate Nursing Education preparation and reaccreditation, changes in leadership of the individual NP programs, and release of the new NONPF Population-Focuses Competencies. These events afforded ample opportunity to map the program outcomes to the competencies, the Essentials of Doctoral Education for Advanced Nursing Practice, and the program outcomes that fostered discussions within and across the NP tracks. These discussions identified strategies for collaborative opportunities and sharing resources. Additionally, reanalyzing and increasing clinical expectations resulted in further efforts for enhanced student preparation for clinical practice and enhanced relationships with practice partners and may result in a larger impact to serve diverse and rural settings. Program faculty and leadership continue to refine plans of study, scheduling the transition between new and old curricula while maintaining acceptable enrollment across programs, and meet student needs for courses. The support of community stakeholders, including clinical agencies and preceptors, includes not only deep appreciation for their contribution to the development of the new curricula but also ongoing dialogue about requirements and potential changes in foci of the students in their settings with the planned changes. CONCLUSIONS
Independent yet complementary curriculum evaluation and redesign are achievable with intentional activities and accurately providing the necessary time for assessment, communication, collaboration, and transition. This complex and sometimes simultaneous process allowed 2 NP programs to consider and develop opportunities for shared learning events as Volume
-,
Issue
-, -/-
2016
well as enhanced clinical requirements. Issues such as scheduling, staffing, implementing, and assessing outcomes are expected but with a cohesive approach from the beginning can be mitigated. This endeavor of shared understanding and common goals supports student growth beyond core competencies and allows for optimal clinical practice. Finally, this effort provides a foundation for developing clinicians who are systems thinkers prepared to improve the health of individuals and communities while maintaining cost-effective health care, open to change, and poised to positively impact outcomes. References 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Retrieved from http://books.nap.edu/openbook.php?record_ id¼12956&page¼R1. 2011. Accessed August 2, 2016. 2. Berwick D, Nolan T, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. 3. National Organization of Nurse Practitioner Faculties. Population-focused nurse practitioner competencies. http://www.nonpf.org/resource/resmgr/ Competencies/CompilationPopFocusComps2013.pdf. 2013. Accessed August 8, 2016. 4. Earnest M, Brandt B. Aligning practice redesign and interprofessional education to advance triple aim outcomes. J Interprof Care. 2014;28(6):497-500. 5. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. http://www.aacn.nche.edu/dnp/ pdf/essentials.pdf. 2006. Accessed August 8, 2016. 6. American Association of Colleges of Nursing. The doctor of nursing practice: current issues and clarifying recommendations-report from the task force on the implementation of the DNP. Retrieved from http://www.aacn.nche.edu/ aacn publications/white-papers/DNP-Implementation-TF-Report-8-15.pdf. 2015. Accessed August 10, 2016. 7. Huston C. The impact of emerging technology on nursing care: warp speed ahead. Online J Issues Nurs. 2013;18(2):1. 8. LeCuyer E, DeSocio J, Brody M, Schlick R, Menkens R. From objectives to competencies: operationalizing the NONPF PMHNP competencies for use in a graduate curriculum. Arch Psychiatr Nurs. 2009;23:185-199.
www.npjournal.org
9. Tilley D. Competency in nursing: a concept analysis. J Contin Educ Nurs. 2008;39(2):58-64. 10. Anema M, McCoy J. Competency Based Nursing Education: Guide to Achieving Outstanding Learner Outcomes. New York, NY: Springer Publishing; 2010. 11. Richardson L, Resick L, Leonardo M, Pearsall C. Undergraduate students as standardized patients to assess advanced practice nursing student competencies. Nurs Educ. 2009;34(1):12-16. 12. Clark C. Evaluating nurse practitioner students through objective structured clinical examination. Nurs Educ Perspect. 2015;36(1):53-54. 13. Dunsforth J. Structured communication: improving patient safety with SBAR. Nurs Womens Health. 2009;13(5):384-390. 14. Shinnick M, Woo M, Horwich T, Steadman R. Debriefing: the most important component of simulation? Clin Simul Nurs. 2011;7:e105-e111. 15. American Association of Colleges of Nursing. White paper: current state of APRN clinical education. http://www.aacn.nche.edu/APRN-white-paper.pdf. 2105. Accessed August 10, 2016. 16. Dolansky MA, Moore SM. Quality and safety education for nurses (QSEN): the key is systems thinking. Online J Issues Nurs. 2013;18(3):1. 17. McLaughlin J, Roth M, Glatt D, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014;89(2):236-243.
Sandy Carollo, PhD, MSN, FNP-BC, is a Clinical Associate Professor, Associate Dean/Academic Director and FNP Track Coordinator at Washington State University College of Nursing in Yakima, WA, and can be reached at scarollo@ wsu.edu. Anne Mason, DNP, PMHNP-BC, is the DNP Program Director & PMHNP Track Coordinator at Washington State University College of Nursing in Spokane, WA. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.11.011
The Journal for Nurse Practitioners - JNP
e7