From one speculator to another: the framework of nursing curricula

NURSE EDUCATION TODAY

From one speculator to another': the framework of nursing curricula Blair Collister Lecturer in Nursing, Department of Nursing, University of Manchester

This paper identifies the need to plan nursing curricula within a conceptual framework of nursing. It is suggested that the GNC syllabus offers the main framework of nursing education in the UK and that through imaginative interpretation, courses may enhance the practice of nursing and assist in the development of relevant theory.

THE CONCEPT OF curriculum in nursing education appears to be the subject of some confusion. Ideas as to what may be included within the concept cover a wide spectrum. They range from Packer's (1979) general usc of the term to refer to 'philosophy, curriculum design, objectives, learning theories, teaching methods, and evaluation' to Heidgerken's (1965) use of the term to refer specifically to all planned learning experiences of the school. Smith (1975) reflects many writers' belief in the need for nurse teachers to clarify what they mean by 'nursing' before embarking on curriculum design. Many definitions of nursing are available (Wu 1979), and the need for nurse teachers to identify facts, concepts, and statements of relationships relevant to nursing follows from the identification of a conceptual framework. Bevis (1973) describes three problems basic to curriculum building: 1. determining the behaviour required of the product (the nurse); 2. devising a system of experiences to produce the required behaviour; 3. discovering whether th e product exhibits the required behaviours. To overcome the first problem, to identify the behaviours which are exhibited by a nurse, the curriculum designer must have a clear idea as to 'what is nursing'. However, in a survey conducted by Hall 0979) it was discovered that although graduate and undergraduate nursing programmes were being implemented using recognised conceptual models of nursing, a large number of curricula were being planned and implemented without reference to such theoretical backgrounds. This is particularly interesting since in the country in which the survey was conducted-the United States-the National

League for Nursing (NLN) has a mandate requiring all nurse training institutions to develop their curricula within a conceptual framework consistent with the philosophy and objectives of their courses. The results of this survey imply that in a country such as the United Kingdom where no such mandate exists, the number of nurse training schools with no clearly stated philosophy of nursing or education, or conceptual framework on which practice is based, would be very large. Influences from outside the hospital Heidgerken (1965) identifies three levels of curriculum planning, the first of which is the societal curriculum. This is seen as a result of the need for nursing to meet the needs of society, and the consequent reflection of society in curriculum planning. In practice, it is shown by the imposition of conditions on nurse training schools by outside bodies (such as the NLN). These conditions determine the characteristics of curriculum content, sequence, and implementation. In the United Kingdom, the General Nursing Councils approve the conducting of schemes of training for various registers and rolls. To this end, they issue a syllabus of training for each register and roll, which is updated from time to time. Essential theoretical and clinical requirements are also laid down, and these must be met both for the training schools to gain approval and for the nurses undergoing training to become registered or enrolled upon completion.of training. Thus the syllabus and associated memoranda issued from time to time together form a powerful document in controlling curriculum design in United Kingdom nurse education. It may be suggested that it is this syllabus, rather than philosophical and conceptual considerations, which dictate the form of curricula developed. Training schools are free to interpret the syllabus and must document their interpretation and submit it to the General Nursing Council for approval. However, as Smith (1975) points out, curriculum plans must be realistic, and based on a realistic concept of nursing. Documentation submitted for approval includes the aims and the objectives of the course, details of

*'More reali stically in practice disciplines, there is a triad of "speculators" : the practitioner, the theory builder, and the theory tester or researcher' (Dickoff J & Jame s P (1975) in Verh onick P J (Ed) Nursin g R esearch, Little Brown & Co, Boston)

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NURSE EDUCATION TODAY curriculum development, and details of clinical experience, teaching methods, and evaluation methods. This would be seen to encompass all aspects of Packer's (1979) definition of curriculum outlined earlier, and if the dictates of the syllabus are seen to be the driving force behind the curriculum design, then it may be stated that the major part of curriculum development lies outside the nurse training school. A consequence of such an approach, with the need to implement the regulations for training, not only so that the training school may obtain approval, but also so that nurses may register after training, is that the 'behaviour desired of the product' (Bevis 1973) is described by an agency outside that in which the training takes place. As far as the training school is concerned, the end behaviours desired may only be those of passing hospital and State-conducted Final practical and written examinations. This is a somewhat hypercritical discussion of the lack of philosophical and conceptual themes of nursing curricula. Packer (1979) suggests that stating a philosophy is difficult for nurses, since they are preoccupied with what they ought to believe, rather than what they do believe, and Ellis (1982) states that definitions of concepts germane to nursing are still vague and imprecise. In addition, educators experience conflict between what may be viewed as an intellectual rather than a practice-based profession, and the dichotomy between education and service commitments. Further, nurses work for and with people who may have a preconceived idea about nursing which is at variance with nurses' beliefs about their profession and education. This latter point is echoed by Henderson (1978) who points out that the nurses' concept of nursing may be at odds with their public image. These conflicts, Packer (1979) suggests, make it necessary for nurses to think through their personal philosophy, since if the conflicts are unresolved, nurses' behaviour will reflect uncertainty and be inconsistent.

Characteristics of the well-ordered curriculum Whatever philosophy is adopted by the training institution, there is a need for consistency in curriculum design. Heidgerken (1965) states that curriculum should have continuity, sequence, and organisation, course topics and units should relate horizontally and vertically to provide a systematic expansion of ideas and activities. Smith (1975) suggests that curriculum coordination implies that integration and correlation should be evident. Integration results in the parts relating to a meaningful whole. Wu (1979), citing Tyrer, states that integration refers to the horizontal relationship of curriculum experiences and unifies the elements at each level of the curriculum. Correlation means that related topics should appear together in the curriculum. iD 1983 Longman Group L'd.

Continuity, according to Wu (1979), refers to the vertical threads of the curriculum, in which major curricular elements are related over time. Experiences building upon previous ones, adding depth and breadth, produce sequence in curriculum design. In discussing the relative merits of breadth and depth in curriculum elements, Ausubel (1968) comments on the belief that broadening of the curriculum results in a failure to learn 'fundamentals'. The fundamentals to which he refers are the three 'Rs' but the view expressed is not uncommon in nurse education and practice. As the syllabus expands through the addition of new topics and concepts, so nurses complain that learners' education neglects the 'basics' of nursing. However, Ausubel (1968) challenges the tenet that the benefits of expanding a curriculum necessarily produce a deterioration in the standard of basic knowledge. To refute this, he points to more efficient methods of teaching, and the incidental learning of fundamentals which result from broadening the curriculum. He suggests that improving the standards or amount of teaching of fundamentals would be at the expense of other aspects and topics which, in the light of current trends in nursing, would be to the detriment of nursing practice. Ausubel (1968) concedes that there is a point beyond which increased breadth can only be attained by sacrificing the mastery of basics, and experience suggests that there are those who believe that that point has been reached, and possibly passed, in nurse education today. Unifying theories-major reappearing concepts It appears intuitively right that a curriculum should be consistently and purposefully structured, and this leads into the second of Bevis's (1973) problems, that of devising a system of experiences. In a historical analysis of nursing curricula, Stevens (1971) identified four major structural approaches used in developing curricula in nursing. These integrate well with other writers, both within and outside nursing. Stevens (1971) states that, prior to the early 1950s, little attention was given in nursing texts to the form of nursing curricula. It was assumed that teaching was by the disease-centred body-systems approach. This view is supported by Ellis (1982) who suggests that early nurse training course content was identified by observing what nurses were actually doing, and developing curricula to perpetuate the status quo. As medical science developed, so this type of curriculum continued, with diseases and body systems replacing hygiene and environmental management central to early courses. The logistical method The curriculum which has been in use in nursing over the longest period of time is that which centres on disease and body systems. Course content is divided into nursing specialities 33

NURSE EDUCATION TODAY which correspond with medical specialities, and physiological systems each constitute the subjectmatter of a course. Each course focuses on disease or trauma, subdividing into aetiology, pathology, signs and symptoms, and nursing care. Knowledge is amassed as a sumrnative process, and an overall view is eventually achieved with the sequential learning of facts. Understanding comes about through logistical processes, which isolate elements and form relative laws. It does not focus on the whole, but it is hoped that the student will 'view the totality by study of the individual parts'. The logistical method corresponds to the curriculum option described by Packer (1979) as deriving from a realist philosophy. This bases nursing and education on a factual, established body of knowledge, incorporating the medical model, and special subjects. Indeed, Packer used the term 'logistical design' for such a framework. Goals tend to be related to subject-matter, employing instructional objectives rather than desired student behaviour, although behavioural objectives are used for content teaching in individual lessons. Learning theory in the realist curriculum centres on the behaviourist concepts of Skinner, exemplified by stimulus-response (S-R), where the stimulus is the information given and the response is the student behaviour. Teaching is generally through the medium of teacher-centred classroom activities, and since the lecture is the most efficient method of teaching facts, this is the principal method used. In Gott's (1982) recent study, this (the lecture) was still the main teaching method. Supplementary methods include programmed instruction and recitation. Evaluation centres on recall and recognition and learning is tested by objective examination, for example multiple choice questions. Recent trends to multiple choice papers in State final examinations conducted by the General Nursing Council, and in clinical teaching examinations of the Royal College of Nursing, serve to show how this, the realist, logistical approach, is prevalent in nurse education in the United Kingdom. Stevens (1971) suggests that in the logistical concept the nurse is merely instrumental. She provides an environment of rest, diet, hygiene, and ventilation so the patient's body can best fight illness, or heal after trauma. Focus upon the nurse is incidental, and Heidgerken (1965) states that clinical practice is work experience, rather than a learning opportunity, for the student. Heidgerken differentiates various curriculum approaches by suggesting that the purpose is the intellectual development of the learner, then considers four different conceptions of intellectual development. For the concept of curriculum relating to the logistical method intellectual development is seen as mastery of subject-matter, and this corresponds to the realist (Packer) and logistical (Stevens) concepts. 34

The dialectical rnethod The dialectical mode of thought presents a global view, and parts are presented as a function of the whole. Knowledge from any two courses fuses into a larger whole which subsumes the knowledge from subsequent courses. In tracing and identifying departures from the logistical method of curriculum development, Stevens (1971) suggests that the difference between curriculum content and curriculum method is highlighted. The early developments of synthetic (that is a mode which combines conflicting theories, referred to as the thesis and the anti-thesis) methods of curriculum design had varying content. She refers to two such methods which did not have a calculus of disease as their unifying theme. One has as its organising principle a concept of man, from birth to death, with the focus on the healthy individual. The other course mentioned by Stevens to illustrate this method has the health/illness continuum as its organising framework. In this, attention focuses first on the well individual, and progresses through conditions causing minimal disruption to normal functioning to severely debilitating illnesses. Packer (1979) describes a simil ar curriculum option which is based on the idealist philosophy, in which the emphasis is on ideas. Basic concepts (ideas) are selected by the teaching staff and nursing courses are built around these concepts. Students are considered, if not involved when goals and objectives are stated, since they will be required to organise ideas. Learning theories related to student activities are also employed, theories in which intervening variables present in the S-R schemata. Neobehaviourists such as Hebb, and Gestalt psychology with its emphasis on insight learning and cognitive styles and structures, all contribute to the development of lectures and student-cent red activities such as discussion groups. Evaluation of learning takes place using methods which allow student expression such as essays, short answer responses, and objective tests of students' organisation of ideas. The nurse is involved in the concept of 'total nursing care' and is said to nurse the patient rather than the disease. The nurse meets the physical, emotional, psychological, and spiritual needs of the patient. Thus nursing is given a holistic framework, with a concept of either man or health and illness as the focus. Stevens (1971) points out that some curricula combine elements of both the logistical and dialectical methods, and suggests that such efforts reflect a realistic way of dealing with the expanding role of the nurse and the demands this places on nurse education, while at the same time preserving unity in the curriculum. The operational method In this programme no prestructured curriculum D 1983 Lo ngman G roup L IJ .

NURSE EDUCATION TODAY exists, but is developed in response to students' needs. Students are placed on wards for observation, and thereafter decide their learning needs. Stevens (1971) notes that students invariably select procedural skills to learn first. Students then select individual patients to study to fulfil their learning needs. Stevens challenges the assertion that such a curriculum is primarily patientcentred. Although the students' focus is on individual patients, rather than 'man' in the abstract, the purpose of such a focus is to teach the student rather than care for the patient. It is suggested that the primary focus is the students' learning needs, and the patient serves to organise the students' knowledge. The term 'operational' refers to the students' selection of the patient, and which aspects of the patient, to study. Thus its validity lies in the operations of the student reflecting operational, discriminating processes. The pragmatist operational design described by Packer (1979) displays the characteristics outlined above. This is based on the premise that the student will want to learn that which attracts him and has meaning for him. There is less concern for the measurement of learning process and focus is on the affective development of the student. Heidgerken (1965) sees the emphasis resting on interpersonal relationships and group techniques, and Packer (1979) suggests that the teacher acts as a learning resource and provides an environment in which the learner can fulfil the learning contract which incorporates the students' individual goals and objectives. While students participate in the evaluation of achievement, and may have input to examination content, problems may arise in clinical evaluation. Packer (1979) further emphasises the problems of such a curriculum in that many teachers find it difficult to relinquish authoritarian control. In addition the programme demands creativity, flexibility, and greater teaching and administrative skills than other plans. The nurse in such a programme is seen as an agent of intervention, and health is attained through manipulation. The problematic method The fourth method identified by Stevens (1971) is that in which the focus is a problem situation. The student identifies a specific problem experienced by the patient in relation to a physiological, biological, or socio-psychological need. Abdella's (1960) '21 nursing problems' is offered as an example of the problem-solving approach in nursing education and practice, although Abdella's definition of a nursing problem (a condition faced by the patient which the nurse can help him to face through the performance of her professional functions) is challenged on the grounds that it can be equated with patient problem. The problem-solving method in education had as one of its chief exponents John Dewwy who is cited D 1983 Longman Group Ltd.

by Stevens (1971) and Heidgerken (1965) as equating intellectual development with the development of the process of problem-solving and creative thought. Mastering the subject-matter is seen as secondary to activity-centred learning. through problem-solving experience, which means that the nurse becomes part of the problem situation. Health is seen as an objective to be achieved through overcoming obstacles, and an important point to note is that although two nurses may have the same objectives, the means that each use to gain the objective may differ since identical activities could not be expected from each nurse. The use of the problem-solving approach, with its emphasis on clinical activity, fits in with the concept of nursing as a practice discipline and this is seen by Stevens (1971) as one of its major strengths. She also notes two ways in which problems may be used in an operational mode: on the one hand, patients are tools to illustrate problems, while on the other hand problems are tools to study patients. Heidgerken (1965) suggests that in some instances there may be a greater emphasis on problems than on problem-solving, and that such an emphasis views problems as subject-matter. Such an approach would therefore be logistical rather than problem-solving. Consequences for curriculum development The identification of structure underlying nursing curriculum should, according to Stevens (1971), facilitate the students' learning and the teachers' performance. For the student, the foundation laid by a single consistent approach can be built upon by the nurse after course completion. The nurse can continue learning by integrating new with existing knowledge. The teacher is given a clear understanding of methodologies through a thorough grasp of the structure of the curriculum, and this also helps when changes are planned. With regard to change of curriculum, Stevens (1971) suggests that the push in the United States towards the adoption of the problem-solving method led to many schools adopting the new methods precipitately. A consequence of being pressed into problem-solving modes is that a teacher continues in the logistical mode, adopts the new terminology, and feels that she has changed to the new methodology. This is a particularly interesting observation in view of the shift towards the nursing process in the educational policy of the General Nursing Council (1977) and in the syllabus.issued subsequently. Although the syllabus is open to interpretation such interpretation tends not to be a question of belief or preference, but one of fact. Stevens (1971) states that 'nursing education can profit more by diversity than by conformity' in training schemes, but such diversity does not appear possible in the United Kingdom, with evaluation of programmes resting with a central governing body rather than with those responsible for designing the curriculum. 35

NURSE EDUCATION TODAY Problems of standardised achievement tests, according to Ausubel (1968), include the tendencies (a) to cover ground ignored by new curricula, and .(b) to fail to measure knowledge of new concepts emphasised by new curricula. Thus Bevis's (1973) third problem-that of discovering whether the product (nurse) exhibits the required behaviour-is encountered and through it the problem of evaluating curricula. The integrated curriculum Packer (1979) suggests that the pressing issue is the implementation of an integrated curriculum. Heidgerken (1955) states that an integrated course needs a fusion' of ideas from related fields and a synthetic principle to bind its content together. The need for a synthesising principle would place it outside a logical realist method, and Packer (1979) describes a 'broadfields' curriculum lying between the realist and idealist philosophies. In such a curriculum, facts would be taught as a related science, and the unifying theme would be the theory of nursing and related concepts. Stevens (1971) describes attempts to integrate courses and suggests that they do not escape the logistical mode since they represent another way of presenting a body-systems approach. Richards (1977) reports the empirical evaluation of an integrated curriculum. The definition of learning and its measurement and knowledge content imply a logistical frame of reference. Burgess (1978) identifies the two orientations (subjects and process) in nursing curricula and suggests that most are a combination of both. As an alternative she suggests a person orientation, since most curricula give at least implicit references to the development of the nurse as a person. However, must a synthetic or integrated curriculum 'escape' the logistical method? If nursing is taken to be. a practice-based profession and practice takes place in reality, then surely a realist philosophy must enter into curriculum design as it would in the practice. To deny its existence may well lead to the situation described by Altschul (1972) and Towell (1975) in which psychiatric nurses faced with conflicting ideological viewpoints have no clear idea of the alternatives available, or of their own standpoint, and use terms without knowing their precise meaning or significance. Sharp (1964) also points out that when students are taught in situations in which conflict exists between theory and practice; then nurses' use of language is loose and imprecise. It is interesting to note Stevens' (1971) discussion of future curriculum trends. She identifies two tendencies, each involving a familiar method with a new content. The first is an extension of the problem-solving process evolving new problems and focal points. If, as previously suggested, problems constitute subjectmatter, then surely this is an extension in the logistical mode. 36

The other trend referred to as a return to the logistical mode is exemplified by a focus not on disease, but on diagnosis and planning of care in a rigid predictable way. The nurse becomes a technician responsible for collecting and interpreting data from the patient, and once the diagnosis has been established the appropriate model of nursing care is applied. Probability theory can be employed to reduce the possible choices in reaching the goal of nursing equilibrium. Stevens bases her prediction on literature sources, and an additional reason may be the increase in litigation rendering it necessary for nurses to eliminate any chance of error (Ellis 1980). Whatever the reason, the realities of a profession practising in an environment in which the client is becoming more aware and where standards must be established and maintained imply a need for a realityorientated curriculum. A bridge

To give consistency to continuing education and practice a bridge, a unifying link, is required. Although there exists a need for philosophy, theory, and models in nursing, the practice of nursing has to continue while such are developed, and nurse education has to continue to provide practitioners. It would seem that the nursing process may offer a framework in which nursing practice and education may be structured. To have the practice of nursing structured within the framework of the nursing process may provide the means whereby practice can be researched to expand and identify theory and models. In addition it may give a unifying theme to minimise the dichotomy between service and education, described by many and demonstrated by Gott (1982). The use of nursing process as a basis for both teaching and practice may mean that there would no longer be a need for 'reality' advice, and would help practitioners and teachers to decide what may constitute adequate care. This, in turn, would facilitate the identification of behaviours of the end-product of nurse training. Caution However, such a scheme needs to be approached sensibly with adequate preparation for all involved, co-ordinated effort, and perhaps above all the involvement of all in planning and implementing change. It is also important that all should understand the general principles involved, otherwise a curriculum may evolve in which patient problems, nursing action, and the like are regarded merely as facts, dressed up differently, which are rote learned. To take issue with the notion that a problem-solving approach will produce technicians with a rigid approach, attention is directed towards the recent 'discovery' that patients are people. So are nurses, and in the implementation of care nurses can show their individuality particularly in the interpersonal and communicative aspects of care. ~

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NURSE EDUCATION TODAY If nurses are taught in a rigid, authoritarian fashion then it is likely that their approach to care will be rigid. To be flexible requires a certain confidence in self based at least partly on adequate knowledge of alternatives. With so many changes in nurse education at all levels, reassessment will identify the alternatives and provide a curriculum designed to cope successfully with one of the few radical changes the conceptual basis of nursing has seen for over a hundred years.

REFERENCES Abdella F G et al 1960 Patient-centred approaches to nursing, Macmillan, New York. Altschul A 1972 Nurse-patient interaction, Churchill Livingstone, Edinburgh. Ausubcl D P 1968 Educational psychology: a cognitive view, Holt, . Rineheart & Wilson, London. Bevis E M 0 1973 Curriculum building in nursing, C V Mosby, St . Louis, US. Burgess G 1978 The personal development of the nursing student as a conceptual framework', Nursing Forum, 17: 1,96-102. Ellis C 1980 Morbid obesity: a comparative study, Nursing Times occasional paper, 76: 5.

Ellis C 1982 Conceptual issues in nursing, Nursing Outlook 30:7 General Nursing Council 1977 Statement of education policy, Circular 77/19. Gou M 1982 Theories of learning and the teaching of nursing, Nursing Times occasional paper, 78: 11,41-44. Hall K M 1979 Current trends in the use of conceptual frameworks in nursing education, Journal of Nursing Education, 18: 4, 26-29. Heidgerken L 1965 Teaching and learning in schools of nursing (3rd ed), J B Lippincott & Co, Philadelphia. Henderson V 1978 The concept of nursing, Journal of Advanced Nursing, 3, 113-130. Packer J 1979 Curriculum consistency, Journal of Nursing Education, 18: 4, 47-52. Richards M A 1977 One integrated curriculum: an empirical evaluation, Nursing Research, 26: 2, 90-95 . Sharp L 1964 The behavioural scientist in nursing research, Nursing Research, 13: 4, 327-330. Smith J P 1975 College organisations, management and curriculum in Raybould E (Ed), A guide for teachers of nurses, Blackwell Scientific Publications, Oxford. Stevens B J (1971) Analysis of structural forms used in nursing curricula, Nursing Research, 20: 5, 388-397. Towell D 1975 Understanding psychiatric nursing, Royal College of Nursing, London, Wu R R 1979 Designing a curriculum model, Journal of Nursing Education, 18: 13-21.

Curriculum theory in nurse education R A Hoy and A Mustafa Director of Nurse·Education, The Middlesex Hospital, London; Senior Tutor, The Ealing District School of Nursing, London

THE GENERAL NURSING COUNCIL for England and Wales in its education policy documents of 1977 and 1979 lays great emphasis upon the importance of the principles of curriculum development to the planning and hence approval of schemes of training. This point is also underlined by the Joint Board of Clinical Nursing Studies. However there is no curriculum theory related directly to nurse education; indeed, it could be argued that curriculum theory is not applicable to nursing if the instructional element only is considered, which is, of course, the 'historical' approach to the preparation required to enter the nursing profession. But now owing to: • the explosive advance of medical technology; • the realisation of the importance of the patient as a biological, sociological, psychological entity; • increasing professional awareness and a clearer understanding of the role of the nurse as a result of the continued growth of nursing science; • the greater expectations of society; • the changing patterns of illness, © 1983 Longman Group Ltd .

the knowledge base required by the nurse before practical skills can be intelligently applied for the patient's benefit has widened. The first question that is posed therefore is: does the widening of the knowledge base make the theory of curriculum development as applied to general education capable of being transferred, as it were, to nursing? In attempting to answer this question the first step is to find a definition of curriculum that is applicable to nursing. Immediately the difficulty of definition itself arises as the published literature on curriculum theory contains a spectrum of definitions. Maccia in 1965, for example, defined curriculum as 'presented instructional content'. This definition would appear to presuppose the formal classroom teaching situation. Nurses, however, do not learn in the classroom alone. Indeed, it could be argued. that the majority of learning by student nurses takes place informally around the bedside during the normal nurse/patient and nurse/nurse interactions. The Maccia definition, therefore, cannot be used for our purposes, although 37