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Implementing a Concept-Based Nursing Curriculum: A Review of the Literature
Teaching and Learning in Nursing 15 (2020) 66e71
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Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Implementing a Concept-Based Nursing Curriculum: A Review of the Literature Christine L. Repsha, MS, FNP-C, CHSE a,*, Brenna L. Quinn, PhD, RN-BC, NCSN, CNE b, Anya Bostian Peters, PhD, RN, CNE b a b
Clinical Instructor, William F. Connell School of Nursing, Boston College, Maloney Hall, 275, 140 Commonwealth Avenue, Chestnut Hill, MA 02467 Assistant Professor, Solomont School of Nursing, University of Massachusetts Lowell, 113 Wilder Street, Suite 200, Lowell, MA 01854
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Article history: Accepted 30 September 2019
As complexity within the health-care industry grows, concerns regarding the theory-practice gap for new graduate nurses increase. One proposed method for overcoming this gap is a concept-based curriculum (CBC). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines directed this literature review of 23 peer-reviewed articles published between 2008 and 2018 on transitioning to a CBC. Results demonstrated that although transitioning to a CBC has significant challenges in organization, time, and faculty support, it also supported a more interactive learning environment, student-centered teaching, and streamlining of course content. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Keywords: Nursing Curriculum Concept-based Active learning Nursing education
Contents Introduction . . . . . . . . . . . . Purpose . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . Search Procedure . . . . . . . Inclusion and Exclusion Criteria . Data Extraction and Analysis . . . . Results . . . . . . . . . . . . . . Summary of Evidence . . . . . . . CBC Methods . . . . . . . . . . . Planning . . . . . . . . . . . Evaluation . . . . . . . . . . CBC Outcomes . . . . . . . . . . . Student Outcomes . . . . . . . . . Barriers to CBC Implementation . . . Overcoming Challenges. . . . . . . Discussion. . . . . . . . . . . . . Limitations . . . . . . . . . . Conclusion . . . . . . . . . . . . References . . . . . . . . . . . .
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Acknowledgment of financial support: No acknowledgments of financial support to report. * Corresponding author. Tel.: 617-552-4586; fax: 617-552-0931. E-mail address: [email protected] (C.L. Repsha). https://doi.org/10.1016/j.teln.2019.09.006 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
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Introduction
Purpose
Nurse educators are compelled with preparing students to work in a highly challenging, ever-changing health-care environment. In 1998 Tanner published her evaluation of the American Association of Colleges of Nursing (AACN)’s The Essentials of Baccalaureate Education for Professional Nursing calling it the “21-year curriculum”. Twenty years later, although technology and evidence have exploded, little change has occurred in nursing education models. The information age has improved both the depth of and access to new healthcare information. However, it has also contributed to saturation of nursing curricula as faculty members attempt to include all relevant material within a two- or four-year education (Giddens & Brady, 2007). In response, students are frustrated and overwhelmed by the volume of content in nursing courses (Giddens & Brady, 2007; Institute of Medicine, 2011). New graduate nurses are expected to apply knowledge and meet competencies across a variety of care settings including acute care, primary care, and community health in addition to playing a variety of roles such as primary nurse, educator, case manager, and interdisciplinary team member (Giddens & Brady, 2007; National Advisory Council on Nurse Education and Practice, 2010; Phillips et al., 2013). Given the complexity of the modern nursing role, hiring managers seek candidates who are qualified to provide patient-centered care in a safe, effective, and timely manner while tending to the multifaceted needs of patients today (Billings & Halstead, 2016). As the health-care environment becomes increasingly complex, the education-practice gap continues to widen (Giddens &Brady, 2007; National Advisory Council on Nurse Education and Practice, 2010). To close the gap, leading organizations including the Institute of Medicine, National League for Nursing (NLN), and AACN have called for innovation in nursing education through regular faculty evaluation and revision of course content, approaches, and methods of instruction (American Association of Colleges of Nursing, 2008; Institute of Medicine, 2011; National League for Nursing, 2005). New models of nursing education must focus on evidence-based practice, integration of didactic and clinical education, clinical reasoning, and shifting needs within patient populations (Billings & Halstead, 2016; National Advisory Council on Nurse Education and Practice, 2010; Phillips et al., 2013). The NLN has encouraged educators to develop new methods of instruction that are flexible, accessible, and inclusive, while also fostering active participation from class members (National League for Nursing, 2005). Traditionally, patient populations and medical diagnoses provide a framework for the structuring of nursing curricula. A conceptbased curriculum (CBC) is a departure from traditional curriculum (TC). A CBC focuses on teaching core ideas or concepts threaded throughout a curriculum to encourage critical thinking and deeper learning. Concepts are leveled throughout the curriculum to promote greater understanding and application whereas minimizing opportunities for unnecessary repetition or omission (Billings & Halstead, 2016). In doing so, faculty create opportunities for students to expand their knowledge of a concept to a variety of settings, populations, and experiences without needing to explicitly present content in every course (Billings & Halstead, 2016; Giddens & Brady, 2007). For example, instead of teaching about the care of asthma in an assessment course, a pharmacology course, pediatrics, and adult care, students would learn through an exemplar lesson on asthma in children only and would apply concepts learned to the care of adults. A CBC also encourages active teaching strategies including problem-based learning, team-based learning, case studies, and reflection to engage contemporary students (Billings & Halstead, 2016).
The purpose of this review was to (1) describe methods for incorporating CBC into prelicensure nursing programs, (2) summarize outcomes of a CBC, (3) establish barriers to incorporating a CBC, and (4) explore strategies for ameliorating challenges. Through recognizing outcomes, challenges, and facilitators of a CBC, priorities for future research and changes to nursing education practices may be identified. This review is part of an ongoing effort to examine alternative curricular models as nurse educators prepare for the next generation of nursing students. Methods Search Procedure The Preferred Reporting Items for Systematic Reviews and MetaAnalysis (PRISMA) guidelines directed the review process (Moher, Liberati, Tetzlaff, & Altman, 2009). To identify articles for inclusion, the academic databases Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, MEDLINE/PubMed, as well as hand searches of Nurse Educator, Nursing Education Perspectives, Nursing Education Today, Journal of Nursing Education, and Teaching and Learning in Nursing were conducted. Search terms included nurs* educ*, concept based curriculum, and concept based education. Inclusion and Exclusion Criteria Articles describing CBC in nursing education were of interest for the review. Articles meeting the following criteria were included: the studies that (a) described a method for incorporating CBC in prelicensure undergraduate nursing education, (b) were published in peer-reviewed scholarly journals between 2008 and 2018, and (c) were written in the English language. The 2008-2018 search window was used as a 10-year search frame allowing researchers to capture publications that are relevant and timely (Cronin, Ryan, & Coughlan, 2008). Data Extraction and Analysis After selection of articles for inclusion in the review, data were extracted from each article and organized in to a matrix. Extracted data included the year of publication, journal, country of origin, sample, sample size, description of CBC implementation, and results if applicable. The authors performed a directed content analysis to categorize data using the identified study aims (Hsieh & Shannon, 2005). This approach aided in achieving the aim of the present review to identify barriers and facilitators of CBC in undergraduate nursing education. Results A total of 39 nonduplicate articles were found through search of databases and selected journals. Six articles were dissertations and were not available to the researchers because of cost restraints. The remaining 33 were reviewed by title and abstract for inclusion. After a review of the title and abstract of each article, 6 were excluded based on the inclusion and exclusion criteria. Of the remaining 27 sources, four articles were excluded after full-text review. Reasons for exclusion after full-text review included but were not limited to absence of a report of CBC development or implementation. A final sample of 23 original research articles was included for review. Fig. 1 displays the PRISMA diagram.
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Fig. 1. PRISMA Diagram.
All included articles reported use of CBC in the United States. The publication dates of included articles were between 2008 and 2018. Faculty members and undergraduate students from both associates and baccalaureate nursing programs were studied across the included articles. Summary of Evidence Evidence to support all four themes that derived from study aims was identified after analysis. Themes represented methods for incorporating CBC, challenges to incorporating CBC, benefits of CBC, and student outcomes after transition to CBC. CBC Methods Planning A variety of approaches were implemented to explore CBC adoption and plan for CBC implementation. Several nurse researchers (Brady et al., 2008; Giddens, Keller, & Liesveld, 2015; Giddens & Morton, 2010; Higgins & Reid, 2017) detailed the creation of task forces or CBC-specific committees. Brady et al. (2008) used Kanter's (1999) seven skills for change model as an organizing framework for successful change. One research team developed a task force to examine several factors before CBC implementation (Giddens, et al., 2015). The task force recruited current and former students to participate in focus groups, reviewed National Council Licensure Examination (NCLEX) scores and course evaluations, communicated with clinical adjunct faculty members, and surveyed employers to determine satisfaction with program graduates. Site visits to outside universities
with innovative curriculum models were also completed. A second task force launched the CBC after the development of course schedule, new courses, and faculty training. Giddens and Morton (2010) also reported the creation of a CBC committee. Committee members conducted surveys and focus groups to formulate a comprehensive implementation plan. The plan included both formative and summative evaluation, incorporating assessment, accreditation, and benchmarking models. The institution’s TC was phased out over a two-year period. Later, Giddens et al. (2015) reported that committees were formed for curriculum design, concept development, and clinical education/simulation with faculty from all involved schools of nursing. Higgins and Reid (2017) discussed the initial collaboration of eight community colleges and four universities who planned to create a CBC that would be available for any Texas college to adopt. The result of this state-wide committee was the development of concept analysis diagram, template for syllabi, and concept analysis regarding CBC. Other authors (Brussow, Roberts, Scaruto, Sommer, & Mills, 2019; Lewis, 2014; Patterson, Crager, Farmer, Epps, & Schuessler, 2016) spoke specifically about the development of grids and diagrams to guide the CBC advancement. Lewis (2014) developed 14 basic concepts and identified exemplars that would best prepare new graduates as nurse generalists. Patterson et al. (2016) developed a conceptual grid to guide assessment in a CBC. Duncan and Schulz (2015) described the transition from TC to CBC. Both curricula were used concurrently for 4 semesters. In fall 2010, TC students began the second semester of a 5-semester program and the CBC students began the first semester of the 4semester program. Both cohorts graduated together in May 2012. Student outcomes were compared, and discussed in a later section of the present paper.
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Some authors described concept-based approaches to specific nursing courses. For example, Lanz and Davis (2017) implemented a concept-based approach to a pharmacology course. Decker, Hensel, Kuhn, & Priest (2017) implemented community health concepts in various courses throughout the curriculum through lessons, simulations, and clinicals. Hensel (2017) added more community clinicals and created a lifespan course. This course included maternal/newborn nursing care, eliminated pediatrics lecture, and moved those concepts into a broader biophysical nursing course. This program included only community-based or pediatric simulations. Evaluation Researchers compared TC with CBC through several methods. Brady et al. (2008) noted reviewing NCLEX scores, course evaluations, and employers’ satisfaction with graduates as determinants of implementation success. Harrison (2018) evaluated critical thinking skills, NCLEX pass rates, and pass rate prediction scores among associate degree (AD) nursing students completing a CBC. Elliot (2017) evaluated student learning related to professional values for students enrolled in a CBC. Systematic analysis of narrative assignments using framework evaluation methodology was implemented for this purpose. Kumm and Laverentz (2017) completed a five- year evaluation of CBC using course evaluations, concept evaluation, NCLEX success, alumni/employer surveys, and research projects. Murray, Laurent, and Gontarz (2015) developed an evaluation tool for the CBC evaluation. Sportsman and Pleasant (2017) used a mixedmethods approach for the evaluation of CBC implementation in baccalaureate, AD, and licensed practical nursing programs across the country. Deane (2017) completed qualitative interviews via a twoquestion email. Content analysis was used to elicit themes. Gooder and Cantwell (2017) reviewed outcomes via web survey and focus groups. Giddens, Wright, and Gray (2012) sent requests to leaders of 10 schools/consortiums that were using CBC to share which concepts were included in the respective curricula, so concepts could be used consistently across a network of schools. CBC Outcomes Researchers discussed several benefits to using CBC. Multiple authors determined that a CBC supported a more interactive learning environment. Small group activities, class discussions, and peer learning were easier to implement with concept-based teaching (Giddens & Morton, 2010; Gooder & Cantwell, 2017). Instructors more often adhered to a student-centered teaching approach when working within a CBC (Lanz & Davis, 2017). Furthermore, using a CBC allowed for more integration between theory and clinical learning for nursing students (Higgens & Reid, 2017). Students of Hensel (2017) developed an increased interest in community-based nursing after participating in a CBC. Implementing a CBC also provided benefits to the school of nursing. Patterson et al., (2016) found that organizing the CBC allowed for identification of curricular challenges for undergraduate students. Through streamlining course content, the use of a CBC allowed for easier transition from AD programs to BS programs (Giddens et al., 2015). Student Outcomes Several researchers offered reports of student outcomes after a change to CBC. Duncan and Schulz (2015) determined a comparable percentage of students graduated in time both before and after CBC implementation. Similarly, Patterson et al. (2016) noted a consistency among student satisfaction and NCLEX pass rates between groups of
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students who did and did not learn via CBC. Murray et al. (2015) also failed to observe a statistically significant change in NCLEX-RN pass rates and program completion rates. Students in a CBC did not demonstrate any change in their motivation to learn (Fromer, 2017). Although one research team (Fromer, 2017) determined the CBC had no effect on standardized exam scores, another research team (Lanz & Davis, 2017) noted improved scores. A positive impact of CBC on student success was noted in several articles. Following participation in a CBC, student critical thinking scores trended upwards (Patterson et al., 2016). Although NCLEXRN pass rates initially dropped for several schools implementing a CBC, the pass rates surpassed the national average in subsequent years (Deane, 2017; Kumm & Laverentz, 2017). Students reported concerns with a change in NCLEX-RN pass rates and employer satisfaction (Lewis, 2014) when transitioning to a CBC. Despite such concerns, students described feeling empowered and having a sense of increased autonomy after completing their education with a CBC (Decker et al., 2017). Barriers to CBC Implementation As with any major curricular change, there were many challenges involved with implementing a CBC. During planning phases, faculty disagreed on what concepts to include and how those concepts would be defined and organized (Giddens et al., 2012; Patterson et al., 2016). Three researchers reported limits to both time and administrative support in the planning phases created barriers to curriculum change (Deane, 2017; Duncan & Schulz, 2015; Sportsman & Pleasant, 2017). Faculty of two schools of nursing were resistant to change because of a fear of the unknown, fear of dropping firsttime NCLEX pass rates, and lack of knowledge about CBC (Deane, 2017; Hendricks & Wangerin, 2017). Both Duncan and Schulz (2015) and Brady et al. (2008) expressed the challenge of faculty teaching two different curriculums simultaneously during the implementation of the CBC. During this phase, students also expressed that there was repetition and overlap in content and learning activities (Giddens & Morton, 2010; Gooder & Cantwell, 2017; Kumm & Laverentz, 2017). Clinical challenges for a CBC included determining guidelines for clinical experiences and securing community-based clinical placements (Decker et al., 2017; Hensel, 2017). Overcoming Challenges Faculty members participated in a change to CBC-implemented strategies to overcome challenges associated with such a large change. Deane (2017) noted positive self-talk, seeing positive changes for students, and a focus on team building as helpful to the CBC implementation process. Hendricks and Wangerin (2017) suggested culture changes and leadership support as two methods that may facilitate a successful transition to a CBC. The culture shift involves a change in beliefs regarding the role of faculty and what students need to know. Leaders may support the change to a CBC through providing adequate meeting and release time, supporting faculty training, engaging stakeholders, and creating a realistic implementation timeline (Hendricks & Wangerin, 2017). Faculty members may also consider a sequential rollout of CBC, or changing one or two lessons per course to a concept-based approach before changing all curricula (Hendricks & Wangerin, 2017; Sportsman & Pleasant, 2017). Discussion Traditional nursing curricula are saturated with ever-expanding content. Shifting the standard of education from teaching to learning is not a new initiative (Barr & Tagg, 1995). Faculty report feeling
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overwhelmed with the amount of required content in nursing courses (Ellis, 2016). Hall and Walton (2004) estimated that a typical nurse would need to read 17 articles per day to remain up-to-date in their area of specialization. Advances in healthcare and its delivery, as well as the rapid proliferation of nursing research, necessitate curricular changes to keep pace. The knowledge that nursing students will need to find success on licensure exams will not abate, given rapid changes to nursing practices and treatment modalities. Similarly, the amount of knowledge nursing faculty is responsible for including in curriculum will not remit. Despite the growing body of knowledge, nursing programs are not allotted any additional credit hours or instruction time. A method of organizing nursing curriculum other than a traditional population or specialty-centric model is needed. CBC is one method that may help meet the needs of nursing students today. Information overload prevents nursing students from being able to sift through content to determine what is the essential information needed for safe and competent nursing practice applicable to all patient populations (Baron, 2017). Incorporating CBC is one method to promote long-term memory development of crucial concepts that will help students transition from coursework to real practice situations, in addition to ameliorating pressure and challenges faculty members face to include a growing body of content. Significant changes in student satisfaction, or rates of graduation, and NCLEX-RN success graduation rates have been appreciated after CBC implementation (Ellis, 2016; Kumm & Laverentz, 2017; Lewis, 2014; Sportsman & Pleasant, 2017). Schools of nursing can remain viable as long as NCLEX pass rates are acceptable to state nursing boards and prospective students. However, by seizing the opportunity to inculcate concept-based learning into undergraduate nursing curricula, students will graduate with a robust understanding of concepts and be well-prepared to enter the nursing workforce. Further, when schools of nursing embrace and implement CBC and teaching strategies, students learn adaptability. Students are then armed with the capacity to apply conceptual understanding to any patient situation. Transitioning to a CBC does require organization, teamwork, and administrative support. Faculty must understand how concepts and conceptual learning work to support student success. Teaching in a CBC requires a departure from the traditional “sage on the stage” teaching methods and integration of a student-centered teaching approach. Concepts are taught through the use of exemplars, and deep learning occurs through experiential learning and application of concepts. Although many faculty members are accustomed to teaching by body system or medical diagnosis, faculty teaching in a CBC must be open to departing from this traditional content model of organizing curriculum and courses. If a school of nursing chooses CBC adoption, select administrative supports are needed for success. As Deane (2017), Sportsman and Pleasant (2017), and Duncan and Schulz, (2015) described, lack of administrative support was detrimental to their programs’ success in adopting a CBC whereas Hendricks and Wangerin (2017) noted administrative support helped support CBC adoption. Moreover, teaching two separate curriculums at once presented challenges (Brady et al., 2008; Duncan & Schultz, 2015). Plans must be in place for increasing faculty positions to account for reduced workload during the CBC transition and the increase in courses needing instructors during the transition from TC to CBC. Using a CBC also necessitates diverse teaching methods as compared with TC. Incorporating engaging teaching strategies that allow students to make connections with prior knowledge promotes meaningful learning and fosters critical thinking skills n, 2001). Traditional lecture or teacher-focused learning (Limo does not solidify conceptual learning, and may not be the most effective method for developing critical thinking among students.
Critical thinking related to broad concepts is indispensable in today’s ever-changing health-care environment. Nursing faculty may need additional training or mentorship regarding such diverse teaching methods. Providing faculty with professional development opportunities to create appropriate teaching tools is essential. CBC textbook outlines can serve as examples for a school of nursing working to adopt a CBC. However, consulting and involving nurse faculty members within the school of nursing are essential during the CBC planning process. Nurse faculty members should be allowed to contribute their expertise and exercise professional judgment to aid in the selection of concepts and exemplars. Providing room for personalization and input from faculty members can help elicit buy-in, and ensure that concepts and exemplars are relevant to health-care issues impacting the city or community surrounding the school of nursing. Faculty planning a CBC are reminded, however, that mapping the complete CBC is imperative to ensure the new curriculum does not unnecessarily repeat. Doing so will ensure that the CBC increases curriculum efficiency. Although a CBC has many benefits and present research was identified in the present review, several priorities for future research have emerged. The success of new graduates of nursing programs using CBC should be studied. To fully understand the impact of a CBC on clinical reasoning, nurse researchers should compare onboarding challenges that students from TC and CBC face when starting a new job. For example, nurse researchers may identify differences in the length of new graduate orientation between groups of graduates. Limitations The search terms used in this review included nurs* educ*, concept based curriculum, and concept based education. Other sources may exist categorized under different terms. Furthermore, the inclusion of relevant literature depends on the accuracy of indexing within the included databases. Dissertations and theses were not included as sources in this study, given financial limitations. Conclusion Overall, there are many positive outcomes from implementing a CBC. Students felt empowered in their learning, demonstrated increased autonomy, and were more engaged. Teaching in a CBC promotes an interactive learning environment and improves the integration of theoretical learning to application in clinical practice. Nursing faculty require training and support to successfully transition to a CBC. However, implementing a CBC can alleviate challenges faculty face when tasked to include all topics in which nursing students are expected to demonstrate competence. References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacnnursing. org/portals/42/publications/baccessentials08.pdf. Baron, K. A. (2017). Changing to Concept-Based Curricula: The Process for Nurse Educators. The Open Nursing Journal, 11(1), 277e287. https://doi.org/10.2174/1874434601 711010277. Barr, R. B., & Tagg, J. (1995). A New Paradigm For Undergraduate Education. Change: The Magazine of Higher Learning, 27(6), 12e26. https://doi.org/10.1080/00091383.1995. 10544672. Billings, D. M., & Halstead, J. A. (Eds.). (2016). Teaching in nursing: a guide for faculty (Fifth edition). St. Louis, Missouri: Elsevier. Brady, D., Welborn-Brown, P., Smith, D., Giddens, J., Harris, J., Wright, M., & Nichols, R. (2008). Staying Afloat: Surviving Curriculum Change. Nurse Educator, 33(5), 198e201. https://doi.org/10.1097/01.NNE.0000334776.05643.30. Brussow, J. A., Roberts, K., Scaruto, M., Sommer, S., & Mills, C. (2019). Concept-Based Curricula: A National Study of Critical Concepts. Nurse Educator, 44(1), 15e19. https://doi.org/10.1097/NNE.0000000000000515.
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Higgins, B., & Reid, H. (2017). Enhancing “Conceptual Teaching/Learning” in a ConceptBased Curriculum. Teaching and Learning in Nursing, 12(2), 95e102. https://doi.org/ 10.1016/j.teln.2016.10.005. Hsieh, H. F., & Shannon, S. E. (2005). Three Approaches to Qualitative Content Analysis. Qualitative Health Research, 15(9), 1277e1288. https://doi.org/10.1177/ 1049732305276687. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Kanter, R. M. (1999). The enduring skills of change leaders. Leader to Leader, 15e22. https://doi.org/10.1002/ltl.40619991305. Kumm, S., & Laverentz, D. M. (2017). Concept-Based Curriculum Evaluation: 5-Year Process. Teaching and Learning in Nursing, 12(4), 242e245. https://doi.org/10.1016/ j.teln.2017.06.004. Lanz, A., & Davis, R. G. (2017). Pharmacology Goes Concept-Based: Course Design, Implementation, and Evaluation. Nursing Education Perspectives, 38(5), 279e280. https://doi.org/10.1097/01.NEP.0000000000000188. Lewis, L. S. (2014). Outcomes of a concept-based curriculum. Teaching and Learning in Nursing, 9(2), 75e79. https://doi.org/10.1016/j.teln.2013.12.002. n, M. (2001). On the cognitive conflict as an instructional strategy for conceptual Limo change: a critical appraisal. Learning and Instruction, 11(4e5), 357e380. https:// doi.org/10.1016/S0959-4752(00)00037-2. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Journal of Clinical Epidemiology, 62(10), 1006e1012. https://doi.org/10.1016/j.jclinepi.2009 .06.005. Murray, S., Laurent, K., & Gontarz, J. (2015). Evaluation of a concept-based curriculum: A tool and process. Teaching and Learning in Nursing, 10(4), 169e175. https://doi.org/ 10.1016/j.teln.2015.08.002. National Advisory Council on Nurse Education and Practice. (2010). Addressing new challenges facing nursing education: Solutions for a transforming healthcare environment. Retrieved from https://www.hrsa.gov/advisorycommittees/bhpradvisory/ nacnep/Reports/eighthreport.pdf. National League for Nursing. (2005). Transforming nursing education [Position Statement]. Retrieved from http://www.nln.org/docs/default-source/about/archivedposition-statements/transforming052005.pdf?sfvrsn¼6. Patterson, L. D., Crager, J. M., Farmer, A., Epps, C. D., & Schuessler, J. B. (2016). A Strategy to Ensure Faculty Engagement When Assessing a Concept-Based Curriculum. Journal of Nursing Education, 55(8), 467e470. https://doi.org/10.3928/ 01484834-20160715-09. Phillips, J. M., Resnick, J., Boni, M. S., Bradley, P., Grady, J. L., Ruland, J. P., & Stuever, N. L. (2013). Voices of Innovation: Building a Model for Curriculum Transformation. International Journal of Nursing Education Scholarship, 10(1). https://doi.org/ 10.1515/ijnes-2012-0008. Sportsman, S., & Pleasant, T. (2017). Concept-Based Curricula: State of the Innovation. Teaching and Learning in Nursing, 12(3), 195e200. https://doi.org/10.1016/ j.teln.2017.03.001. Tanner, C. A. (1998). Curriculum for the 21st century- Or is it the 21-year curriculum? [Editorial]. Journal of Nursing Education, 37(9), 383e384.
Contents lists available at ScienceDirect
Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Implementing a Concept-Based Nursing Curriculum: A Review of the Literature Christine L. Repsha, MS, FNP-C, CHSE a,*, Brenna L. Quinn, PhD, RN-BC, NCSN, CNE b, Anya Bostian Peters, PhD, RN, CNE b a b
Clinical Instructor, William F. Connell School of Nursing, Boston College, Maloney Hall, 275, 140 Commonwealth Avenue, Chestnut Hill, MA 02467 Assistant Professor, Solomont School of Nursing, University of Massachusetts Lowell, 113 Wilder Street, Suite 200, Lowell, MA 01854
a r t i c l e
i n f o
a b s t r a c t
Article history: Accepted 30 September 2019
As complexity within the health-care industry grows, concerns regarding the theory-practice gap for new graduate nurses increase. One proposed method for overcoming this gap is a concept-based curriculum (CBC). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines directed this literature review of 23 peer-reviewed articles published between 2008 and 2018 on transitioning to a CBC. Results demonstrated that although transitioning to a CBC has significant challenges in organization, time, and faculty support, it also supported a more interactive learning environment, student-centered teaching, and streamlining of course content. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Keywords: Nursing Curriculum Concept-based Active learning Nursing education
Contents Introduction . . . . . . . . . . . . Purpose . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . Search Procedure . . . . . . . Inclusion and Exclusion Criteria . Data Extraction and Analysis . . . . Results . . . . . . . . . . . . . . Summary of Evidence . . . . . . . CBC Methods . . . . . . . . . . . Planning . . . . . . . . . . . Evaluation . . . . . . . . . . CBC Outcomes . . . . . . . . . . . Student Outcomes . . . . . . . . . Barriers to CBC Implementation . . . Overcoming Challenges. . . . . . . Discussion. . . . . . . . . . . . . Limitations . . . . . . . . . . Conclusion . . . . . . . . . . . . References . . . . . . . . . . . .
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Acknowledgment of financial support: No acknowledgments of financial support to report. * Corresponding author. Tel.: 617-552-4586; fax: 617-552-0931. E-mail address: [email protected] (C.L. Repsha). https://doi.org/10.1016/j.teln.2019.09.006 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
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Introduction
Purpose
Nurse educators are compelled with preparing students to work in a highly challenging, ever-changing health-care environment. In 1998 Tanner published her evaluation of the American Association of Colleges of Nursing (AACN)’s The Essentials of Baccalaureate Education for Professional Nursing calling it the “21-year curriculum”. Twenty years later, although technology and evidence have exploded, little change has occurred in nursing education models. The information age has improved both the depth of and access to new healthcare information. However, it has also contributed to saturation of nursing curricula as faculty members attempt to include all relevant material within a two- or four-year education (Giddens & Brady, 2007). In response, students are frustrated and overwhelmed by the volume of content in nursing courses (Giddens & Brady, 2007; Institute of Medicine, 2011). New graduate nurses are expected to apply knowledge and meet competencies across a variety of care settings including acute care, primary care, and community health in addition to playing a variety of roles such as primary nurse, educator, case manager, and interdisciplinary team member (Giddens & Brady, 2007; National Advisory Council on Nurse Education and Practice, 2010; Phillips et al., 2013). Given the complexity of the modern nursing role, hiring managers seek candidates who are qualified to provide patient-centered care in a safe, effective, and timely manner while tending to the multifaceted needs of patients today (Billings & Halstead, 2016). As the health-care environment becomes increasingly complex, the education-practice gap continues to widen (Giddens &Brady, 2007; National Advisory Council on Nurse Education and Practice, 2010). To close the gap, leading organizations including the Institute of Medicine, National League for Nursing (NLN), and AACN have called for innovation in nursing education through regular faculty evaluation and revision of course content, approaches, and methods of instruction (American Association of Colleges of Nursing, 2008; Institute of Medicine, 2011; National League for Nursing, 2005). New models of nursing education must focus on evidence-based practice, integration of didactic and clinical education, clinical reasoning, and shifting needs within patient populations (Billings & Halstead, 2016; National Advisory Council on Nurse Education and Practice, 2010; Phillips et al., 2013). The NLN has encouraged educators to develop new methods of instruction that are flexible, accessible, and inclusive, while also fostering active participation from class members (National League for Nursing, 2005). Traditionally, patient populations and medical diagnoses provide a framework for the structuring of nursing curricula. A conceptbased curriculum (CBC) is a departure from traditional curriculum (TC). A CBC focuses on teaching core ideas or concepts threaded throughout a curriculum to encourage critical thinking and deeper learning. Concepts are leveled throughout the curriculum to promote greater understanding and application whereas minimizing opportunities for unnecessary repetition or omission (Billings & Halstead, 2016). In doing so, faculty create opportunities for students to expand their knowledge of a concept to a variety of settings, populations, and experiences without needing to explicitly present content in every course (Billings & Halstead, 2016; Giddens & Brady, 2007). For example, instead of teaching about the care of asthma in an assessment course, a pharmacology course, pediatrics, and adult care, students would learn through an exemplar lesson on asthma in children only and would apply concepts learned to the care of adults. A CBC also encourages active teaching strategies including problem-based learning, team-based learning, case studies, and reflection to engage contemporary students (Billings & Halstead, 2016).
The purpose of this review was to (1) describe methods for incorporating CBC into prelicensure nursing programs, (2) summarize outcomes of a CBC, (3) establish barriers to incorporating a CBC, and (4) explore strategies for ameliorating challenges. Through recognizing outcomes, challenges, and facilitators of a CBC, priorities for future research and changes to nursing education practices may be identified. This review is part of an ongoing effort to examine alternative curricular models as nurse educators prepare for the next generation of nursing students. Methods Search Procedure The Preferred Reporting Items for Systematic Reviews and MetaAnalysis (PRISMA) guidelines directed the review process (Moher, Liberati, Tetzlaff, & Altman, 2009). To identify articles for inclusion, the academic databases Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, MEDLINE/PubMed, as well as hand searches of Nurse Educator, Nursing Education Perspectives, Nursing Education Today, Journal of Nursing Education, and Teaching and Learning in Nursing were conducted. Search terms included nurs* educ*, concept based curriculum, and concept based education. Inclusion and Exclusion Criteria Articles describing CBC in nursing education were of interest for the review. Articles meeting the following criteria were included: the studies that (a) described a method for incorporating CBC in prelicensure undergraduate nursing education, (b) were published in peer-reviewed scholarly journals between 2008 and 2018, and (c) were written in the English language. The 2008-2018 search window was used as a 10-year search frame allowing researchers to capture publications that are relevant and timely (Cronin, Ryan, & Coughlan, 2008). Data Extraction and Analysis After selection of articles for inclusion in the review, data were extracted from each article and organized in to a matrix. Extracted data included the year of publication, journal, country of origin, sample, sample size, description of CBC implementation, and results if applicable. The authors performed a directed content analysis to categorize data using the identified study aims (Hsieh & Shannon, 2005). This approach aided in achieving the aim of the present review to identify barriers and facilitators of CBC in undergraduate nursing education. Results A total of 39 nonduplicate articles were found through search of databases and selected journals. Six articles were dissertations and were not available to the researchers because of cost restraints. The remaining 33 were reviewed by title and abstract for inclusion. After a review of the title and abstract of each article, 6 were excluded based on the inclusion and exclusion criteria. Of the remaining 27 sources, four articles were excluded after full-text review. Reasons for exclusion after full-text review included but were not limited to absence of a report of CBC development or implementation. A final sample of 23 original research articles was included for review. Fig. 1 displays the PRISMA diagram.
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Fig. 1. PRISMA Diagram.
All included articles reported use of CBC in the United States. The publication dates of included articles were between 2008 and 2018. Faculty members and undergraduate students from both associates and baccalaureate nursing programs were studied across the included articles. Summary of Evidence Evidence to support all four themes that derived from study aims was identified after analysis. Themes represented methods for incorporating CBC, challenges to incorporating CBC, benefits of CBC, and student outcomes after transition to CBC. CBC Methods Planning A variety of approaches were implemented to explore CBC adoption and plan for CBC implementation. Several nurse researchers (Brady et al., 2008; Giddens, Keller, & Liesveld, 2015; Giddens & Morton, 2010; Higgins & Reid, 2017) detailed the creation of task forces or CBC-specific committees. Brady et al. (2008) used Kanter's (1999) seven skills for change model as an organizing framework for successful change. One research team developed a task force to examine several factors before CBC implementation (Giddens, et al., 2015). The task force recruited current and former students to participate in focus groups, reviewed National Council Licensure Examination (NCLEX) scores and course evaluations, communicated with clinical adjunct faculty members, and surveyed employers to determine satisfaction with program graduates. Site visits to outside universities
with innovative curriculum models were also completed. A second task force launched the CBC after the development of course schedule, new courses, and faculty training. Giddens and Morton (2010) also reported the creation of a CBC committee. Committee members conducted surveys and focus groups to formulate a comprehensive implementation plan. The plan included both formative and summative evaluation, incorporating assessment, accreditation, and benchmarking models. The institution’s TC was phased out over a two-year period. Later, Giddens et al. (2015) reported that committees were formed for curriculum design, concept development, and clinical education/simulation with faculty from all involved schools of nursing. Higgins and Reid (2017) discussed the initial collaboration of eight community colleges and four universities who planned to create a CBC that would be available for any Texas college to adopt. The result of this state-wide committee was the development of concept analysis diagram, template for syllabi, and concept analysis regarding CBC. Other authors (Brussow, Roberts, Scaruto, Sommer, & Mills, 2019; Lewis, 2014; Patterson, Crager, Farmer, Epps, & Schuessler, 2016) spoke specifically about the development of grids and diagrams to guide the CBC advancement. Lewis (2014) developed 14 basic concepts and identified exemplars that would best prepare new graduates as nurse generalists. Patterson et al. (2016) developed a conceptual grid to guide assessment in a CBC. Duncan and Schulz (2015) described the transition from TC to CBC. Both curricula were used concurrently for 4 semesters. In fall 2010, TC students began the second semester of a 5-semester program and the CBC students began the first semester of the 4semester program. Both cohorts graduated together in May 2012. Student outcomes were compared, and discussed in a later section of the present paper.
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Some authors described concept-based approaches to specific nursing courses. For example, Lanz and Davis (2017) implemented a concept-based approach to a pharmacology course. Decker, Hensel, Kuhn, & Priest (2017) implemented community health concepts in various courses throughout the curriculum through lessons, simulations, and clinicals. Hensel (2017) added more community clinicals and created a lifespan course. This course included maternal/newborn nursing care, eliminated pediatrics lecture, and moved those concepts into a broader biophysical nursing course. This program included only community-based or pediatric simulations. Evaluation Researchers compared TC with CBC through several methods. Brady et al. (2008) noted reviewing NCLEX scores, course evaluations, and employers’ satisfaction with graduates as determinants of implementation success. Harrison (2018) evaluated critical thinking skills, NCLEX pass rates, and pass rate prediction scores among associate degree (AD) nursing students completing a CBC. Elliot (2017) evaluated student learning related to professional values for students enrolled in a CBC. Systematic analysis of narrative assignments using framework evaluation methodology was implemented for this purpose. Kumm and Laverentz (2017) completed a five- year evaluation of CBC using course evaluations, concept evaluation, NCLEX success, alumni/employer surveys, and research projects. Murray, Laurent, and Gontarz (2015) developed an evaluation tool for the CBC evaluation. Sportsman and Pleasant (2017) used a mixedmethods approach for the evaluation of CBC implementation in baccalaureate, AD, and licensed practical nursing programs across the country. Deane (2017) completed qualitative interviews via a twoquestion email. Content analysis was used to elicit themes. Gooder and Cantwell (2017) reviewed outcomes via web survey and focus groups. Giddens, Wright, and Gray (2012) sent requests to leaders of 10 schools/consortiums that were using CBC to share which concepts were included in the respective curricula, so concepts could be used consistently across a network of schools. CBC Outcomes Researchers discussed several benefits to using CBC. Multiple authors determined that a CBC supported a more interactive learning environment. Small group activities, class discussions, and peer learning were easier to implement with concept-based teaching (Giddens & Morton, 2010; Gooder & Cantwell, 2017). Instructors more often adhered to a student-centered teaching approach when working within a CBC (Lanz & Davis, 2017). Furthermore, using a CBC allowed for more integration between theory and clinical learning for nursing students (Higgens & Reid, 2017). Students of Hensel (2017) developed an increased interest in community-based nursing after participating in a CBC. Implementing a CBC also provided benefits to the school of nursing. Patterson et al., (2016) found that organizing the CBC allowed for identification of curricular challenges for undergraduate students. Through streamlining course content, the use of a CBC allowed for easier transition from AD programs to BS programs (Giddens et al., 2015). Student Outcomes Several researchers offered reports of student outcomes after a change to CBC. Duncan and Schulz (2015) determined a comparable percentage of students graduated in time both before and after CBC implementation. Similarly, Patterson et al. (2016) noted a consistency among student satisfaction and NCLEX pass rates between groups of
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students who did and did not learn via CBC. Murray et al. (2015) also failed to observe a statistically significant change in NCLEX-RN pass rates and program completion rates. Students in a CBC did not demonstrate any change in their motivation to learn (Fromer, 2017). Although one research team (Fromer, 2017) determined the CBC had no effect on standardized exam scores, another research team (Lanz & Davis, 2017) noted improved scores. A positive impact of CBC on student success was noted in several articles. Following participation in a CBC, student critical thinking scores trended upwards (Patterson et al., 2016). Although NCLEXRN pass rates initially dropped for several schools implementing a CBC, the pass rates surpassed the national average in subsequent years (Deane, 2017; Kumm & Laverentz, 2017). Students reported concerns with a change in NCLEX-RN pass rates and employer satisfaction (Lewis, 2014) when transitioning to a CBC. Despite such concerns, students described feeling empowered and having a sense of increased autonomy after completing their education with a CBC (Decker et al., 2017). Barriers to CBC Implementation As with any major curricular change, there were many challenges involved with implementing a CBC. During planning phases, faculty disagreed on what concepts to include and how those concepts would be defined and organized (Giddens et al., 2012; Patterson et al., 2016). Three researchers reported limits to both time and administrative support in the planning phases created barriers to curriculum change (Deane, 2017; Duncan & Schulz, 2015; Sportsman & Pleasant, 2017). Faculty of two schools of nursing were resistant to change because of a fear of the unknown, fear of dropping firsttime NCLEX pass rates, and lack of knowledge about CBC (Deane, 2017; Hendricks & Wangerin, 2017). Both Duncan and Schulz (2015) and Brady et al. (2008) expressed the challenge of faculty teaching two different curriculums simultaneously during the implementation of the CBC. During this phase, students also expressed that there was repetition and overlap in content and learning activities (Giddens & Morton, 2010; Gooder & Cantwell, 2017; Kumm & Laverentz, 2017). Clinical challenges for a CBC included determining guidelines for clinical experiences and securing community-based clinical placements (Decker et al., 2017; Hensel, 2017). Overcoming Challenges Faculty members participated in a change to CBC-implemented strategies to overcome challenges associated with such a large change. Deane (2017) noted positive self-talk, seeing positive changes for students, and a focus on team building as helpful to the CBC implementation process. Hendricks and Wangerin (2017) suggested culture changes and leadership support as two methods that may facilitate a successful transition to a CBC. The culture shift involves a change in beliefs regarding the role of faculty and what students need to know. Leaders may support the change to a CBC through providing adequate meeting and release time, supporting faculty training, engaging stakeholders, and creating a realistic implementation timeline (Hendricks & Wangerin, 2017). Faculty members may also consider a sequential rollout of CBC, or changing one or two lessons per course to a concept-based approach before changing all curricula (Hendricks & Wangerin, 2017; Sportsman & Pleasant, 2017). Discussion Traditional nursing curricula are saturated with ever-expanding content. Shifting the standard of education from teaching to learning is not a new initiative (Barr & Tagg, 1995). Faculty report feeling
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overwhelmed with the amount of required content in nursing courses (Ellis, 2016). Hall and Walton (2004) estimated that a typical nurse would need to read 17 articles per day to remain up-to-date in their area of specialization. Advances in healthcare and its delivery, as well as the rapid proliferation of nursing research, necessitate curricular changes to keep pace. The knowledge that nursing students will need to find success on licensure exams will not abate, given rapid changes to nursing practices and treatment modalities. Similarly, the amount of knowledge nursing faculty is responsible for including in curriculum will not remit. Despite the growing body of knowledge, nursing programs are not allotted any additional credit hours or instruction time. A method of organizing nursing curriculum other than a traditional population or specialty-centric model is needed. CBC is one method that may help meet the needs of nursing students today. Information overload prevents nursing students from being able to sift through content to determine what is the essential information needed for safe and competent nursing practice applicable to all patient populations (Baron, 2017). Incorporating CBC is one method to promote long-term memory development of crucial concepts that will help students transition from coursework to real practice situations, in addition to ameliorating pressure and challenges faculty members face to include a growing body of content. Significant changes in student satisfaction, or rates of graduation, and NCLEX-RN success graduation rates have been appreciated after CBC implementation (Ellis, 2016; Kumm & Laverentz, 2017; Lewis, 2014; Sportsman & Pleasant, 2017). Schools of nursing can remain viable as long as NCLEX pass rates are acceptable to state nursing boards and prospective students. However, by seizing the opportunity to inculcate concept-based learning into undergraduate nursing curricula, students will graduate with a robust understanding of concepts and be well-prepared to enter the nursing workforce. Further, when schools of nursing embrace and implement CBC and teaching strategies, students learn adaptability. Students are then armed with the capacity to apply conceptual understanding to any patient situation. Transitioning to a CBC does require organization, teamwork, and administrative support. Faculty must understand how concepts and conceptual learning work to support student success. Teaching in a CBC requires a departure from the traditional “sage on the stage” teaching methods and integration of a student-centered teaching approach. Concepts are taught through the use of exemplars, and deep learning occurs through experiential learning and application of concepts. Although many faculty members are accustomed to teaching by body system or medical diagnosis, faculty teaching in a CBC must be open to departing from this traditional content model of organizing curriculum and courses. If a school of nursing chooses CBC adoption, select administrative supports are needed for success. As Deane (2017), Sportsman and Pleasant (2017), and Duncan and Schulz, (2015) described, lack of administrative support was detrimental to their programs’ success in adopting a CBC whereas Hendricks and Wangerin (2017) noted administrative support helped support CBC adoption. Moreover, teaching two separate curriculums at once presented challenges (Brady et al., 2008; Duncan & Schultz, 2015). Plans must be in place for increasing faculty positions to account for reduced workload during the CBC transition and the increase in courses needing instructors during the transition from TC to CBC. Using a CBC also necessitates diverse teaching methods as compared with TC. Incorporating engaging teaching strategies that allow students to make connections with prior knowledge promotes meaningful learning and fosters critical thinking skills n, 2001). Traditional lecture or teacher-focused learning (Limo does not solidify conceptual learning, and may not be the most effective method for developing critical thinking among students.
Critical thinking related to broad concepts is indispensable in today’s ever-changing health-care environment. Nursing faculty may need additional training or mentorship regarding such diverse teaching methods. Providing faculty with professional development opportunities to create appropriate teaching tools is essential. CBC textbook outlines can serve as examples for a school of nursing working to adopt a CBC. However, consulting and involving nurse faculty members within the school of nursing are essential during the CBC planning process. Nurse faculty members should be allowed to contribute their expertise and exercise professional judgment to aid in the selection of concepts and exemplars. Providing room for personalization and input from faculty members can help elicit buy-in, and ensure that concepts and exemplars are relevant to health-care issues impacting the city or community surrounding the school of nursing. Faculty planning a CBC are reminded, however, that mapping the complete CBC is imperative to ensure the new curriculum does not unnecessarily repeat. Doing so will ensure that the CBC increases curriculum efficiency. Although a CBC has many benefits and present research was identified in the present review, several priorities for future research have emerged. The success of new graduates of nursing programs using CBC should be studied. To fully understand the impact of a CBC on clinical reasoning, nurse researchers should compare onboarding challenges that students from TC and CBC face when starting a new job. For example, nurse researchers may identify differences in the length of new graduate orientation between groups of graduates. Limitations The search terms used in this review included nurs* educ*, concept based curriculum, and concept based education. Other sources may exist categorized under different terms. Furthermore, the inclusion of relevant literature depends on the accuracy of indexing within the included databases. Dissertations and theses were not included as sources in this study, given financial limitations. Conclusion Overall, there are many positive outcomes from implementing a CBC. Students felt empowered in their learning, demonstrated increased autonomy, and were more engaged. Teaching in a CBC promotes an interactive learning environment and improves the integration of theoretical learning to application in clinical practice. Nursing faculty require training and support to successfully transition to a CBC. However, implementing a CBC can alleviate challenges faculty face when tasked to include all topics in which nursing students are expected to demonstrate competence. References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacnnursing. org/portals/42/publications/baccessentials08.pdf. Baron, K. A. (2017). Changing to Concept-Based Curricula: The Process for Nurse Educators. The Open Nursing Journal, 11(1), 277e287. https://doi.org/10.2174/1874434601 711010277. Barr, R. B., & Tagg, J. (1995). A New Paradigm For Undergraduate Education. Change: The Magazine of Higher Learning, 27(6), 12e26. https://doi.org/10.1080/00091383.1995. 10544672. Billings, D. M., & Halstead, J. A. (Eds.). (2016). Teaching in nursing: a guide for faculty (Fifth edition). St. Louis, Missouri: Elsevier. Brady, D., Welborn-Brown, P., Smith, D., Giddens, J., Harris, J., Wright, M., & Nichols, R. (2008). Staying Afloat: Surviving Curriculum Change. Nurse Educator, 33(5), 198e201. https://doi.org/10.1097/01.NNE.0000334776.05643.30. Brussow, J. A., Roberts, K., Scaruto, M., Sommer, S., & Mills, C. (2019). Concept-Based Curricula: A National Study of Critical Concepts. Nurse Educator, 44(1), 15e19. https://doi.org/10.1097/NNE.0000000000000515.
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