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Student Experiences With a Newly Developed Concept-Based Curriculum
Teaching and Learning in Nursing xxx (2016) xxx–xxx
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Teaching and Learning in Nursing journal homepage: www.jtln.org
Student Experiences With a Newly Developed Concept-Based Curriculum Valerie Gooder, PhD, RN ⁎, Sally Cantwell, PhD, RN Weber State University, 3875 Stadium Way, Dept. 3903, Ogden, UT 84408, United States
a r t i c l e
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Article history: Accepted 22 November 2016 Available online xxxx Keywords: Curriculum revision Concept based Student experience Student perception Transition
a b s t r a c t Background: Curriculum change is a constant in nursing education. Little is known about the impact of curricular change on nursing students. Method: To determine the overall impact of the change to the concept-based curriculum on the students, we conducted a survey and focus groups. Results: The students were satisfied with the new curriculum but identified barriers to their learning. Conclusion: Faculty implementing a curriculum revision should consider the impact of the changes on the students.
© 2016 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Introduction Revision of curriculum is a constant process within nursing programs. Traditional nursing curriculum involving systems-based learning is straining under the weight of increasing content and an inability to foster critical thinking. The Institute of Medicine and The Carnegie Foundation for the Advancement of Teaching recommended a shift from abstract theory and knowledge toward contextual knowledge and clinical reasoning (Benner, Sutphen, Leonard, & Day, 2010; IOM, 2010). There have been initiatives that encourage systematic and fundamental changes in the way that nursing is taught in order to strengthen the skills of nurses coming out of educational programs and to promote lifelong learning (Benner et al., 2010; IOM, 2010). Recently, there has been a movement in nursing education toward concept-based learning (Giddens et al., 2008). Rather than focusing on organ systems and specific diseases, conceptbased learning focuses on the underlying concepts behind all illnesses and human conditions. The concept-based learning model is significantly different from traditional systems-based learning. Instead of focusing on pneumonia, the focus is on oxygenation. This makes it possible for students to apply the concept to a myriad of clinical conditions and across the lifespan. Concept-based learning has been advocated as a pedagogy to improve student outcomes (Giddens & Morton, 2010; Lasater & Nelson, 2009). Our school of ⁎ Corresponding author. Tel.: +1 801 626-6137. E-mail addresses: [email protected] (V. Gooder), [email protected] (S. Cantwell).
nursing (SON) determined that it was necessary to complete a change to a concept-based curriculum. The process of curriculum revision has an impact on students, but little is known about the experience of students during the transition from a traditional curriculum to a concept-based curriculum. The SON is an articulated program with an associate of science in nursing program (AS) and a registered nurse to baccalaureate of science in nursing (RN-BSN) program. The curriculum revision reduced the AS program total credit hours and changed the RN-BSN from a 2-year program to a 1-year program. The 3 + 1 model allows for 100% of the AS students to move on to the RN-BSN program; over 90% of the AS graduates choose to continue with the RN-BSN program. This equates to the majority of the RN-BSN students being novice nurses. Concepts taught in the AS program, in addition to the exemplars, focused on basic, generic competencies and skills required for the National Council Licensure Exam-Registered Nurse (NCLEX-RN). The RN-BSN program expanded on the concepts and exemplars introduced in the AS program. As a faculty, we were interested in understanding the overall impact of the change of curriculum on students. We undertook a mixed method study to provide information about the experience of the students during the first semester of the curriculum revision process. Background The current curriculum was evaluated, and a new concept-based curriculum was written. A continuous challenge in higher education is preventing students from simply memorizing and repeating information. A concept-based curriculum was chosen because students
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Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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need to be exposed to learning where they experience an increase in retention, committed participation in their learning, deeper levels of understanding, develop the ability to generalize a concept across the lifespan, and have an increase in overall motivation (Anderson & Tredway, 2009; Erickson, 2002; Giddens, 2009). During the implementation of the revised curriculum, the impact of the change on the students was evaluated by individual surveys and student focus groups. The purpose for these evaluations was to determine students' perceptions of the change in curriculum and the perceived effect on their learning. When the SON faculty evaluated the current curriculum, it was found to be content heavy and systems based, which was not adequately preparing students for practice. New outcomes were written for both the AS and RN-BSN programs based on the Quality and Safety Education for Nurses (QSEN) Competencies. The change to a conceptbased pedagogy required changes in all courses' student learning outcomes and affected students entering the program and those continuing. Theoretical Framework Alves and Raposo (2007) Conceptual Framework of Student Satisfaction in Higher Education postulates that students place more of an emphasis on the way education is provided (organization and delivery on canvas) rather than the quality (curriculum design) of the education itself. Although functional value, including quality of programs, is a priority of nursing faculty, it did not translate to high satisfaction of students. Literature Review The transition from a systems-based, content-driven curriculum to a concept-based curriculum is a complicated process because of many factors, including but not limited to faculty motivation, the lack of resources and time, an impending faculty shortage, lack of control over external factors, and limited evaluation materials on successful implementation of concept-based learning. Although this transition is challenging, the literature supports the need for curriculum focused on student-centered learning, improved critical thinking and clinical reasoning skills, and a decrease in content overload (Anderson & Tredway, 2009; Erickson, 2002; Giddens et al., 2008; Martin, 2002). There are a variety of publications and research on concept-based curriculum but limited information on students' perceptions of curriculum change. Following a method implemented by Giddens and Morton (2010), two levels of assessment were delivered to students within the first semester of the concept-based curriculum implementation: individual surveys and focus groups. Focus Groups A focus group interview is a form of qualitative research, which has not been popular outside of business studies until recently (Cheng, 2014). Focus group interviews include a moderator who is impartial to the discussion and has no influence on the group being interviewed (Cheng, 2014). Often, participants are surrounded by their peers and perceive the experience as social and comfortable. Data gathered in focus group interviews are not discovered in individual surveys or individual interviews (Connelly, 2015). Focused on an optimal approach to qualitative research, including focus groups and interviews, Tong, Sainsbury, and Craig (2007) identified a 32-item checklist for successfully reporting on qualitative research. Findings include three domains: (a) research team and reflexivity, (b) study design, and (c) analysis and findings. Each domain details steps that, when reported appropriately, will communicate the value found in the qualitative findings. Cheng (2014), with a focus
on various areas in academia, and Connelly, (2015) with a focus on nursing, support these study findings. A focus on setting, duration of interviews, open-ended versus focused questions, and data saturation are key areas repeated throughout the literature as valuable to data collection. Focus group interviews are used to study many areas of interest in education and may be used as a valuable data collection method (Traynor, 2015). Curriculum Change and Students Students' perceptions of change are not the same as faculty member's perceptions. A change in curriculum causes transition stress for both faculty and students. The word transition, as defined by Merriam-Webster Online Dictionary (n.d.), is the passage, movement, development, or evolution from one stage, state, subject, or place to another. Transition is a change; it takes time and often requires major adjustments. Pena (2010) proposed a perspective on students experiencing transition in education. He identified characteristics that impact the learning of students during a transition. These include the following: (a) novices are not passive learners who just follow rules; (b) novices need freedom; (c) there is always an experience of personal responsibility; and (d) for an expert, intuition only represents a portion of the problem-solving process, which is always analytical besides intuitive; experts need implicit but also explicit knowledge (Pena, 2010). Many faculty are not experienced in the skill of real-time conflict resolution surrounding course changes. Volden and Melland (1999) reported on an effective small-group process they performed with students to facilitate change and manage conflict in the classroom. Anderson and Tredway (2009) implemented a “backward design” (p. 112) approach to curriculum development and focused on the same concepts of perceived change, including students' perception of “acceptable evidence” of understanding. In this approach to curriculum redesign, students are utilized as stakeholders in the curriculum. With the overall goal to promote critical thinking and to create a student-centered course, Anderson and Tredway (2009) discovered a solution to address change and increase student involvement. Students' input and perceptions were used to evaluate the course and make changes they found valuable to the application of their learning and required skills. Nixon and Williams (2014) utilized this same perspective on the value of student input in overall curriculum design and learning. In an effort to keep curriculum fresh and engaging, faculty developed a module focused on student engagement and preparation for reallife application. Although students did not redesign the curriculum, they were the focus of this creative implementation made by faculty. When students are considered and included in the evaluation of curriculum, the literature reflects increased satisfaction for both faculty and students (Erickson, 2002; Giddens & Morton, 2009; Giddens et al., 2008; Nixon & Williams, 2014). Method Design A combination of qualitative and quantitative methods was used to achieve the study objectives. Students were surveyed via an anonymous electronic questionnaire midsemester following implementation of the concept-based curriculum. Student volunteers from the same student sample met in focus groups later in the semester to address specific questions related to their experiences with the newly developed curriculum in the classroom. The focus group coordinator asked the following three questions: “What is helping you learn in this course?” “What changes would assist you in learning?” and “Any other comments you have specifically related to the strengths
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
V. Gooder, S. Cantwell / Teaching and Learning in Nursing xxx (2016) xxx–xxx
and weaknesses of the concept based curriculum.” The remainder of the questions were directed by the student comments and served to clarify their responses. Descriptive statistics were used to describe student responses to the anonymous electronic questionnaire. Demographic information was collected using database queries and provided as grouped data to the researchers. The open-ended questions and focus group transcripts were analyzed using a phenomenological approach to qualitative data analysis. Phenomenology is a well-accepted form of qualitative research in nursing (Dowling & Cooney, 2012; Scheckel, Emery, & Nosek, 2010). For this part of the research, the focus was on describing the phenomena. Husserlian phenomenology, as described by Wojnar and Swanson (2007), allows for exploring and describing the phenomena and a determination of the essences of the lived experience of the students as they experienced the new curriculum. The four-step process advocated by Colaizzi in 1978 (Edward & Welch, 2011) includes (a) bracketing, (b) analyzing, (c) intuiting, and (d) describing. Sample and Recruitment During the fall semester, a revised concept-based curriculum was implemented at the SON for both the AS and RN-BSN programs. The revised curriculum was developed using a model proposed by Erickson (2002) and adapted to nursing by Giddens et al. (2008). Approval by the university institutional review board was obtained prior to conducting the study. All data were collected during the fall semester. Questionnaires The revised curriculum was implemented in the fall throughout the AS and the RN and RN-BSN programs at the school. All students enrolled in AS and RN-BSN courses were given the opportunity to complete a survey; at the same time, they completed end-of-course faculty and course evaluations. All students in the two programs were contacted through e-mail and encouraged to participate. A convenience sampling method was used that included all students who completed the questionnaire. Focus Groups Subjects for the focus group were solicited by a separate informational e-mail asking for their participation in an on-campus focus group in the fall of 2012. Students were contacted by e-mail request by the administrative secretary of the SON inquiring if they wished to participate. Students who agreed to participate were given instructions on how to participate in the focus group. Participants in the focus groups were entered into a drawing for an iPod Touch ® and/ or Kindle Fire®.
The survey consisted of six questions (Questions 1–4 using a Likert scale and Questions 5–6 were open ended). The comments from Questions 5 and 6 were analyzed using qualitative methods (Table 1). Focus Groups A facilitator from outside the SON conducted the focus groups. An administrative assistant from the SON audiotaped the focus group. The facilitator conducted the focus groups using small group instructional diagnosis (Volden & Melland, 1999). Small group instructional diagnosis is a method for structuring a focus group that has the goal of improving instruction. Focusing the discussion on improving instruction provided insight into the students' experience of changing to a concept-based teaching method. This method includes a facilitator meeting with students. The facilitator introduced the topic and presented the consent forms. No SON faculty were present during the focus groups. Group members were asked to think about what the change to the revised curriculum meant to them personally. The group was divided into smaller groups and then came back together as a larger group. The focus groups were audiotaped, and the tapes were transcribed verbatim by administrative assistants. Data Analysis Questionnaire Analysis The first four questions were evaluated using Statistical Package for the Social Sciences (SPSS) 20.0 ® software. Percentages for age, gender, and program were generated to summarize sample characteristics. Open-ended questions (Questions 5 and 6) were analyzed using thematic analysis and NVivo 10®. Focus Groups Textual data were examined by immersion and line-by-line thematic analysis using NVivo 10®. Transcripts were analyzed to identify common themes and meanings within the narrative data. The two researchers reviewed the transcripts individually and found data saturation. They then met to discuss differences and similarities of their individual analysis. A consensus was reached on all differences. Each researcher brought a different perspective, thereby reducing bias and increasing trustworthiness of the data analysis. Qualitative data were reviewed using Colazzi's method (Edward & Welch, 2011).
Table 1 Questions included in the on-line survey.
Data Collection
Question type
Question text
Questionnaire
Likert (1 – strongly disagree and 5 – completely agree)
1. The concepts and outcomes for this course were defined and related to school of nursing competencies. 2. The course activities and assignments enhanced my understanding of course concepts. 3. The activities and assignments in the course units assisted me to achieve unit and course outcomes. 4. Concept-based learning was an effective way to gain new knowledge and increase my nursing skills. 5. What do you see as a strength of the concept-based curriculum? 6. What do you see as a weakness of the concept-based curriculum?
The questionnaire, developed by the researchers, was made available on a university-based on-line testing program to all students. Subjects for the questionnaire were recruited by a solicitation email sent to all students enrolled in AS and RN-BSN programs located on six different campuses (n = 762). All RN-BSN and AS nursing students were encouraged to complete the evaluation available to them on ChiTester (a locally developed secure on-line testing system). The informational e-mail and instructions on the questionnaire itself indicated that completion of the survey was voluntary and implied informed consent.
3
Open ended
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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Themes and exemplars from both the questionnaire analysis and focus groups were shared with faculty and student representatives at program-level faculty meetings. Both faculty and student representatives reported that the findings were consistent with their experiences. Results Student Surveys Ninety-five students between the ages of 20 and 56 years completed the on-line questionnaire, 41 from the AS program and 54 from the RN-BSN program. The AS program is 100% face-to-face. For the RN-BSN students, 40 were in the hybrid group, and 14 were in the on-line group. Hybrid students came to campus for five 3-hourlong face-to-face classes each semester, with the rest of the course taught on-line. For the AS group, there were 34 females and 7 males. For the BSN group there were 45 females and 9 males. The average age for the AS group was 27.59 (SD = 7.19). For the BSN group, the average age was 29.92 (SD = 7.65). Textual data from Questions 5 and 6 on the questionnaire were combined with the focus group and analyzed to identify key themes. Results From Student Surveys Surveys reflected scores consistently as satisfied or completely satisfied on Questions 1–4. See Table 2. Focus Groups
“Posting DQ and then having to reply to each other. I think we gain knowledge from each other. If you don't understand something one of the other students usually has explained it in one of their DQ question.” Enhancing Critical Thinking Students found that the new curriculum fostered critical thinking “Critical thinking skills are enhanced through concept-based curriculum. It gives more three dimensional concept to teaching. Learn to understand as opposed to just memorizing.” “Allows for critical thinking rather than memorization and regurgitation of material. Allows for exploration of the ideas and concepts rather than just the direction that the instructor sees. A lot of good information was presented by students as well.”
Facilitating Learning The students identified the ability of the revised curriculum to facilitate their learning. “I think the strength in this kind of curriculum is that it puts the information in chunks for us. In that way it seems easier for me to learn and the information makes more sense because the multiple layers of the same concept help me absorb it better.”“The idea of concept-based curriculum is a good one. You do want the students to learn how to think rather than spout off the information straight from the textbook.”“I like that I can learn a concept in nursing and immediately put it into practice. I feel like I'm a better, more competent nurse.”
Eight students participated in the focus groups (five females/ three males). Results from Focus Groups Qualitative data analysis highlighted three main themes: one that indicated that the newly revised curriculum was successful and one indicating that there were areas for improvement. The two primary themes were identified as facilitating learning and dissatisfiers. Mixed feelings became a theme when students had both positive and negative views on topics. Within the facilitating learning theme, participants indicated positive aspects of participating in discussions, enhancing critical thinking, facilitating learning, enhancing peer relationships, and applying new learning. Redundancy, infective pedagogy, newness, and teacher characteristics were identified as dissatisfiers. There was also thematic support for some areas that the students clearly differed in their opinions. This theme was labeled mixed feelings and included faculty relationships and group work. Facilitates Learning Participating in Discussions Overall, students viewed group discussions assignments as a facilitator to learning.
Enhancing Peer Relationships Overall, students found that new peer relationships encouraged in the curriculum revision were beneficial to learning. “And we are teaching each other as students too. It's not just the teacher teaching us which is really nice.”“My peers have work experience. And they are all in completely different random fields. And there are different lengths or experience. Like there are people who just started out and there are people who have been a nurse for 20 years. And different age ranges and family statuses. So it kind of supports the diversity of experiences that the students bring in.”
Applying New Learning Students found that they could apply the concepts to real-life situations. “The fact that you have to read and understand material to answer the discussions, so I have to take time to read and learn something new. If it is too easy, despite the fact that I want to learn, I will take the faster and easier way so I like that the material was easy to read, but I learned a lot.
Table 2 Survey results (scale 1–5; 1 – completely dissatisfied, 5 – completely satisfied) Question
n
Mean
SD
The concepts and outcomes for this course were defined and related to school of nursing competencies. The course activities and assignments enhanced my understanding of course concepts. The activities and assignments in the course units assisted me to achieve unit and course outcomes. Concept-based learning was an effective way to gain new knowledge and increase my nursing skills.
95 95 95 94
3.87 3.78 3.75 3.86
0.937 1.044 1.010 1.001
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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“I feel that it helps prepare me for real life experiences rather than just being able to answer some questions on a test.”
Dissatisfaction Redundancy Redundancy was identified as a problem in both programs. Students perceived this as unnecessary busy work. “We have some repetition in assignments with several classes. Having to repeat assignments that are very similar in subject manner for several classes creates busy work.”“Some classes having the same outline and requiring the same homework, it is busy work at that time.” Some viewed redundancy as a positive characteristic. “Many of the concepts cross over between several classes and the learning is reinforced.”
Ineffective Pedagogy The students were not happy with sole use of lectures in the classroom, particularly in the RN-BSN program. “Because we want to take those discussions that are online and maybe tie them into the class. Maybe something like that instead of power point lectures.”“Sometimes there are concepts that don't seem to fit well with the other ones.”
Newness Students recognized the change in the focus of the curriculum and thought that it would require an adjustment by students. “I've noticed this year with the power point, like last year it seemed like they do a power point and we have a power point and we'd be following along taking notes. And then this year they're presenting on a power point but nobody's taking notes and we are all just listening. And I don't know if it's because it is online where we can look at it later. But I sit there and get nervous because I'm thinking should I be taking notes? But we're not having a test on it.”“Nursing school was a lot of memorizing and repetition. I think it can be a little frightening for students to be expected to know the bigger picture instead of focusing on the little details. I don't think the curriculum is a weakness, I think the change can be difficult for some students.”“It's just different and harder to study for. The way the test questions are worded makes it more difficult. For instance, I can explain a concept to you in detail but when asked to answer the test question there may not be enough detail and the options can be vague. It seems no matter how much more time I study I cannot do any better on the test. From a student standpoint memorization is a lot easier and less time consuming. However, I understand that the concepts are much more important learn.”
Teacher Characteristics Clearly, some faculty were more prepared and organized than others. “No teaching on the teacher's part. I feel like all I am doing is waiting for grades on papers that I have written.” “Don't know of any really problems with it. This class in particular was just poorly organized by the professor. I've spent half the time trying to figure out what was expected of me.”
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Mixed Results Faculty Relationships Some students reported feeling supported by the instructors, and some did not. “I think the concept-based curriculum is great but there is no teaching on the teacher's part. All they do is grade assignments.” “They're on your team. They want you to learn it because they want to give you their impression. It's like this is what I know because I've been through it now let me give this information to you.”
Group Work Students disagreed on the value of group work. “I also think that the use of groups for the online class is a little difficult to complete and do a good job on as it is hard to meet with group members.”“I don't know if what's been helping me has anything to do with new curriculum but I found that working in groups tends to be really helpful for me. I've been able to make some friends and we're all kind of going through the same things so we can help each other and remind each other of assignments and stuff.”
Discussion The curriculum revision team was interested in determining the impact of the newly revised curriculum change on students. The majority of the students indicated on the survey that they viewed the change to the new concept-based curriculum model positively (Table 2). Analysis of the qualitative data indicated that there were positive and negative impacts to students. Students experienced difficulty because of the newness, some redundancy, and specific faculty characteristics but also described positive experiences with the revised curriculum. Students were generally positive about the discussion assignments, enhanced critical thinking, the facilitation of learning, enhanced peer relationships, and application of new learning. Students found benefit in discussions that encouraged linking of concepts and higher level learning. They learned from the instructor and other students. They valued the interactions with diverse student groups. Students reported understanding of concepts, rather than memorization, and viewed this positively. They identified benefits of the new curriculum and felt that they were more prepared for real-life experiences. Negative aspects identified by students included redundancy. They objected to “busy work.” However, some students found redundancy to be a positive characteristic, specifically, when the concept was more challenging. They reported perceptions of ineffective pedagogy, such as over reliance on PowerPoint slides ®. They noted that the new curriculum seemed to be a difficult transition for some faculty. For example, students reported disorganization and confusing instruction. The students mentioned the effects of the adjustment of faculty to the curriculum on their learning. They also reported feeling insecure in the transition from memorization to critical thinking in concept-based learning. Students disagreed on the quality of teaching provided by the faculty. Some felt that faculty were disengaged and overwhelmed, whereas others reported faculty participating in more of a mentoring role. Another theme that emerged and students disagreed on was the topic of on-line group work. Some felt that group work made it difficult to complete assignments, whereas others found that group work improved their learning process.
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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Limitations
Acknowledgments
A limitation for this study would be the small sample participating in the focus groups, although we achieved data saturation. Despite thorough instructions in the introductory e-mail, we may have had a larger sample size if we advertised in the school of nursing bulletin boards and had faculty mention the study in their classes. This may have also improved the number of questionnaire responses. Faculty considering involving students in evaluation of curriculum implementation should use multiple methods for recruitment. Students are busy, and single sources of information could be overlooked. The qualitative data from the surveys were included in the analysis, and this mitigated some of the issues with the small sample size. A second limitation was that data for the AS and the BSN in the ladder program were not analyzed separately. More than 90% of the AS students immediately transition to the BSN program following graduation. As a result, the majority of the RN-BSN students are novice nurses. However, there may have been differences in the two groups based on their level of program during the study. Although we invited all students to participate, some students had not been previous students in the SON but would have been exposed to traditional learning in their general education classes. The findings may be most applicable to ladder programs similar to our SON.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Recommendations The findings of the study reinforced that presentation of the material trumped value and quality. These findings are consistent with the model proposed by Alves and Raposo (2007). Faculty considering curriculum revision should focus on areas that impact course presentation. The courses need to be examined for consistency and unnecessary redundancy. Instructions and presentation of course material need to be clear, and discussions need to be well organized. Consideration should be given to utilizing innovative pedagogy, such as flipping the classroom. As students noted, there were some faculty who found the transition to a concept-based curriculum difficult. This reinforces the need for early and comprehensive faculty preparation and development. Unprepared faculty negatively impact the presentation of courses and, thus, reduce students' satisfaction. Conclusion The current study is one of the first of its kind to examine student satisfaction with implementation of a revised concept-based curriculum. The findings highlight both positive and negative perceptions of the curriculum. These findings emphasize the importance of course presentation and support and guidance to faculty when considering a curriculum revision.
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Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Student Experiences With a Newly Developed Concept-Based Curriculum Valerie Gooder, PhD, RN ⁎, Sally Cantwell, PhD, RN Weber State University, 3875 Stadium Way, Dept. 3903, Ogden, UT 84408, United States
a r t i c l e
i n f o
Article history: Accepted 22 November 2016 Available online xxxx Keywords: Curriculum revision Concept based Student experience Student perception Transition
a b s t r a c t Background: Curriculum change is a constant in nursing education. Little is known about the impact of curricular change on nursing students. Method: To determine the overall impact of the change to the concept-based curriculum on the students, we conducted a survey and focus groups. Results: The students were satisfied with the new curriculum but identified barriers to their learning. Conclusion: Faculty implementing a curriculum revision should consider the impact of the changes on the students.
© 2016 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Introduction Revision of curriculum is a constant process within nursing programs. Traditional nursing curriculum involving systems-based learning is straining under the weight of increasing content and an inability to foster critical thinking. The Institute of Medicine and The Carnegie Foundation for the Advancement of Teaching recommended a shift from abstract theory and knowledge toward contextual knowledge and clinical reasoning (Benner, Sutphen, Leonard, & Day, 2010; IOM, 2010). There have been initiatives that encourage systematic and fundamental changes in the way that nursing is taught in order to strengthen the skills of nurses coming out of educational programs and to promote lifelong learning (Benner et al., 2010; IOM, 2010). Recently, there has been a movement in nursing education toward concept-based learning (Giddens et al., 2008). Rather than focusing on organ systems and specific diseases, conceptbased learning focuses on the underlying concepts behind all illnesses and human conditions. The concept-based learning model is significantly different from traditional systems-based learning. Instead of focusing on pneumonia, the focus is on oxygenation. This makes it possible for students to apply the concept to a myriad of clinical conditions and across the lifespan. Concept-based learning has been advocated as a pedagogy to improve student outcomes (Giddens & Morton, 2010; Lasater & Nelson, 2009). Our school of ⁎ Corresponding author. Tel.: +1 801 626-6137. E-mail addresses: [email protected] (V. Gooder), [email protected] (S. Cantwell).
nursing (SON) determined that it was necessary to complete a change to a concept-based curriculum. The process of curriculum revision has an impact on students, but little is known about the experience of students during the transition from a traditional curriculum to a concept-based curriculum. The SON is an articulated program with an associate of science in nursing program (AS) and a registered nurse to baccalaureate of science in nursing (RN-BSN) program. The curriculum revision reduced the AS program total credit hours and changed the RN-BSN from a 2-year program to a 1-year program. The 3 + 1 model allows for 100% of the AS students to move on to the RN-BSN program; over 90% of the AS graduates choose to continue with the RN-BSN program. This equates to the majority of the RN-BSN students being novice nurses. Concepts taught in the AS program, in addition to the exemplars, focused on basic, generic competencies and skills required for the National Council Licensure Exam-Registered Nurse (NCLEX-RN). The RN-BSN program expanded on the concepts and exemplars introduced in the AS program. As a faculty, we were interested in understanding the overall impact of the change of curriculum on students. We undertook a mixed method study to provide information about the experience of the students during the first semester of the curriculum revision process. Background The current curriculum was evaluated, and a new concept-based curriculum was written. A continuous challenge in higher education is preventing students from simply memorizing and repeating information. A concept-based curriculum was chosen because students
http://dx.doi.org/10.1016/j.teln.2016.11.002 1557-3087/© 2016 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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need to be exposed to learning where they experience an increase in retention, committed participation in their learning, deeper levels of understanding, develop the ability to generalize a concept across the lifespan, and have an increase in overall motivation (Anderson & Tredway, 2009; Erickson, 2002; Giddens, 2009). During the implementation of the revised curriculum, the impact of the change on the students was evaluated by individual surveys and student focus groups. The purpose for these evaluations was to determine students' perceptions of the change in curriculum and the perceived effect on their learning. When the SON faculty evaluated the current curriculum, it was found to be content heavy and systems based, which was not adequately preparing students for practice. New outcomes were written for both the AS and RN-BSN programs based on the Quality and Safety Education for Nurses (QSEN) Competencies. The change to a conceptbased pedagogy required changes in all courses' student learning outcomes and affected students entering the program and those continuing. Theoretical Framework Alves and Raposo (2007) Conceptual Framework of Student Satisfaction in Higher Education postulates that students place more of an emphasis on the way education is provided (organization and delivery on canvas) rather than the quality (curriculum design) of the education itself. Although functional value, including quality of programs, is a priority of nursing faculty, it did not translate to high satisfaction of students. Literature Review The transition from a systems-based, content-driven curriculum to a concept-based curriculum is a complicated process because of many factors, including but not limited to faculty motivation, the lack of resources and time, an impending faculty shortage, lack of control over external factors, and limited evaluation materials on successful implementation of concept-based learning. Although this transition is challenging, the literature supports the need for curriculum focused on student-centered learning, improved critical thinking and clinical reasoning skills, and a decrease in content overload (Anderson & Tredway, 2009; Erickson, 2002; Giddens et al., 2008; Martin, 2002). There are a variety of publications and research on concept-based curriculum but limited information on students' perceptions of curriculum change. Following a method implemented by Giddens and Morton (2010), two levels of assessment were delivered to students within the first semester of the concept-based curriculum implementation: individual surveys and focus groups. Focus Groups A focus group interview is a form of qualitative research, which has not been popular outside of business studies until recently (Cheng, 2014). Focus group interviews include a moderator who is impartial to the discussion and has no influence on the group being interviewed (Cheng, 2014). Often, participants are surrounded by their peers and perceive the experience as social and comfortable. Data gathered in focus group interviews are not discovered in individual surveys or individual interviews (Connelly, 2015). Focused on an optimal approach to qualitative research, including focus groups and interviews, Tong, Sainsbury, and Craig (2007) identified a 32-item checklist for successfully reporting on qualitative research. Findings include three domains: (a) research team and reflexivity, (b) study design, and (c) analysis and findings. Each domain details steps that, when reported appropriately, will communicate the value found in the qualitative findings. Cheng (2014), with a focus
on various areas in academia, and Connelly, (2015) with a focus on nursing, support these study findings. A focus on setting, duration of interviews, open-ended versus focused questions, and data saturation are key areas repeated throughout the literature as valuable to data collection. Focus group interviews are used to study many areas of interest in education and may be used as a valuable data collection method (Traynor, 2015). Curriculum Change and Students Students' perceptions of change are not the same as faculty member's perceptions. A change in curriculum causes transition stress for both faculty and students. The word transition, as defined by Merriam-Webster Online Dictionary (n.d.), is the passage, movement, development, or evolution from one stage, state, subject, or place to another. Transition is a change; it takes time and often requires major adjustments. Pena (2010) proposed a perspective on students experiencing transition in education. He identified characteristics that impact the learning of students during a transition. These include the following: (a) novices are not passive learners who just follow rules; (b) novices need freedom; (c) there is always an experience of personal responsibility; and (d) for an expert, intuition only represents a portion of the problem-solving process, which is always analytical besides intuitive; experts need implicit but also explicit knowledge (Pena, 2010). Many faculty are not experienced in the skill of real-time conflict resolution surrounding course changes. Volden and Melland (1999) reported on an effective small-group process they performed with students to facilitate change and manage conflict in the classroom. Anderson and Tredway (2009) implemented a “backward design” (p. 112) approach to curriculum development and focused on the same concepts of perceived change, including students' perception of “acceptable evidence” of understanding. In this approach to curriculum redesign, students are utilized as stakeholders in the curriculum. With the overall goal to promote critical thinking and to create a student-centered course, Anderson and Tredway (2009) discovered a solution to address change and increase student involvement. Students' input and perceptions were used to evaluate the course and make changes they found valuable to the application of their learning and required skills. Nixon and Williams (2014) utilized this same perspective on the value of student input in overall curriculum design and learning. In an effort to keep curriculum fresh and engaging, faculty developed a module focused on student engagement and preparation for reallife application. Although students did not redesign the curriculum, they were the focus of this creative implementation made by faculty. When students are considered and included in the evaluation of curriculum, the literature reflects increased satisfaction for both faculty and students (Erickson, 2002; Giddens & Morton, 2009; Giddens et al., 2008; Nixon & Williams, 2014). Method Design A combination of qualitative and quantitative methods was used to achieve the study objectives. Students were surveyed via an anonymous electronic questionnaire midsemester following implementation of the concept-based curriculum. Student volunteers from the same student sample met in focus groups later in the semester to address specific questions related to their experiences with the newly developed curriculum in the classroom. The focus group coordinator asked the following three questions: “What is helping you learn in this course?” “What changes would assist you in learning?” and “Any other comments you have specifically related to the strengths
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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and weaknesses of the concept based curriculum.” The remainder of the questions were directed by the student comments and served to clarify their responses. Descriptive statistics were used to describe student responses to the anonymous electronic questionnaire. Demographic information was collected using database queries and provided as grouped data to the researchers. The open-ended questions and focus group transcripts were analyzed using a phenomenological approach to qualitative data analysis. Phenomenology is a well-accepted form of qualitative research in nursing (Dowling & Cooney, 2012; Scheckel, Emery, & Nosek, 2010). For this part of the research, the focus was on describing the phenomena. Husserlian phenomenology, as described by Wojnar and Swanson (2007), allows for exploring and describing the phenomena and a determination of the essences of the lived experience of the students as they experienced the new curriculum. The four-step process advocated by Colaizzi in 1978 (Edward & Welch, 2011) includes (a) bracketing, (b) analyzing, (c) intuiting, and (d) describing. Sample and Recruitment During the fall semester, a revised concept-based curriculum was implemented at the SON for both the AS and RN-BSN programs. The revised curriculum was developed using a model proposed by Erickson (2002) and adapted to nursing by Giddens et al. (2008). Approval by the university institutional review board was obtained prior to conducting the study. All data were collected during the fall semester. Questionnaires The revised curriculum was implemented in the fall throughout the AS and the RN and RN-BSN programs at the school. All students enrolled in AS and RN-BSN courses were given the opportunity to complete a survey; at the same time, they completed end-of-course faculty and course evaluations. All students in the two programs were contacted through e-mail and encouraged to participate. A convenience sampling method was used that included all students who completed the questionnaire. Focus Groups Subjects for the focus group were solicited by a separate informational e-mail asking for their participation in an on-campus focus group in the fall of 2012. Students were contacted by e-mail request by the administrative secretary of the SON inquiring if they wished to participate. Students who agreed to participate were given instructions on how to participate in the focus group. Participants in the focus groups were entered into a drawing for an iPod Touch ® and/ or Kindle Fire®.
The survey consisted of six questions (Questions 1–4 using a Likert scale and Questions 5–6 were open ended). The comments from Questions 5 and 6 were analyzed using qualitative methods (Table 1). Focus Groups A facilitator from outside the SON conducted the focus groups. An administrative assistant from the SON audiotaped the focus group. The facilitator conducted the focus groups using small group instructional diagnosis (Volden & Melland, 1999). Small group instructional diagnosis is a method for structuring a focus group that has the goal of improving instruction. Focusing the discussion on improving instruction provided insight into the students' experience of changing to a concept-based teaching method. This method includes a facilitator meeting with students. The facilitator introduced the topic and presented the consent forms. No SON faculty were present during the focus groups. Group members were asked to think about what the change to the revised curriculum meant to them personally. The group was divided into smaller groups and then came back together as a larger group. The focus groups were audiotaped, and the tapes were transcribed verbatim by administrative assistants. Data Analysis Questionnaire Analysis The first four questions were evaluated using Statistical Package for the Social Sciences (SPSS) 20.0 ® software. Percentages for age, gender, and program were generated to summarize sample characteristics. Open-ended questions (Questions 5 and 6) were analyzed using thematic analysis and NVivo 10®. Focus Groups Textual data were examined by immersion and line-by-line thematic analysis using NVivo 10®. Transcripts were analyzed to identify common themes and meanings within the narrative data. The two researchers reviewed the transcripts individually and found data saturation. They then met to discuss differences and similarities of their individual analysis. A consensus was reached on all differences. Each researcher brought a different perspective, thereby reducing bias and increasing trustworthiness of the data analysis. Qualitative data were reviewed using Colazzi's method (Edward & Welch, 2011).
Table 1 Questions included in the on-line survey.
Data Collection
Question type
Question text
Questionnaire
Likert (1 – strongly disagree and 5 – completely agree)
1. The concepts and outcomes for this course were defined and related to school of nursing competencies. 2. The course activities and assignments enhanced my understanding of course concepts. 3. The activities and assignments in the course units assisted me to achieve unit and course outcomes. 4. Concept-based learning was an effective way to gain new knowledge and increase my nursing skills. 5. What do you see as a strength of the concept-based curriculum? 6. What do you see as a weakness of the concept-based curriculum?
The questionnaire, developed by the researchers, was made available on a university-based on-line testing program to all students. Subjects for the questionnaire were recruited by a solicitation email sent to all students enrolled in AS and RN-BSN programs located on six different campuses (n = 762). All RN-BSN and AS nursing students were encouraged to complete the evaluation available to them on ChiTester (a locally developed secure on-line testing system). The informational e-mail and instructions on the questionnaire itself indicated that completion of the survey was voluntary and implied informed consent.
3
Open ended
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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Themes and exemplars from both the questionnaire analysis and focus groups were shared with faculty and student representatives at program-level faculty meetings. Both faculty and student representatives reported that the findings were consistent with their experiences. Results Student Surveys Ninety-five students between the ages of 20 and 56 years completed the on-line questionnaire, 41 from the AS program and 54 from the RN-BSN program. The AS program is 100% face-to-face. For the RN-BSN students, 40 were in the hybrid group, and 14 were in the on-line group. Hybrid students came to campus for five 3-hourlong face-to-face classes each semester, with the rest of the course taught on-line. For the AS group, there were 34 females and 7 males. For the BSN group there were 45 females and 9 males. The average age for the AS group was 27.59 (SD = 7.19). For the BSN group, the average age was 29.92 (SD = 7.65). Textual data from Questions 5 and 6 on the questionnaire were combined with the focus group and analyzed to identify key themes. Results From Student Surveys Surveys reflected scores consistently as satisfied or completely satisfied on Questions 1–4. See Table 2. Focus Groups
“Posting DQ and then having to reply to each other. I think we gain knowledge from each other. If you don't understand something one of the other students usually has explained it in one of their DQ question.” Enhancing Critical Thinking Students found that the new curriculum fostered critical thinking “Critical thinking skills are enhanced through concept-based curriculum. It gives more three dimensional concept to teaching. Learn to understand as opposed to just memorizing.” “Allows for critical thinking rather than memorization and regurgitation of material. Allows for exploration of the ideas and concepts rather than just the direction that the instructor sees. A lot of good information was presented by students as well.”
Facilitating Learning The students identified the ability of the revised curriculum to facilitate their learning. “I think the strength in this kind of curriculum is that it puts the information in chunks for us. In that way it seems easier for me to learn and the information makes more sense because the multiple layers of the same concept help me absorb it better.”“The idea of concept-based curriculum is a good one. You do want the students to learn how to think rather than spout off the information straight from the textbook.”“I like that I can learn a concept in nursing and immediately put it into practice. I feel like I'm a better, more competent nurse.”
Eight students participated in the focus groups (five females/ three males). Results from Focus Groups Qualitative data analysis highlighted three main themes: one that indicated that the newly revised curriculum was successful and one indicating that there were areas for improvement. The two primary themes were identified as facilitating learning and dissatisfiers. Mixed feelings became a theme when students had both positive and negative views on topics. Within the facilitating learning theme, participants indicated positive aspects of participating in discussions, enhancing critical thinking, facilitating learning, enhancing peer relationships, and applying new learning. Redundancy, infective pedagogy, newness, and teacher characteristics were identified as dissatisfiers. There was also thematic support for some areas that the students clearly differed in their opinions. This theme was labeled mixed feelings and included faculty relationships and group work. Facilitates Learning Participating in Discussions Overall, students viewed group discussions assignments as a facilitator to learning.
Enhancing Peer Relationships Overall, students found that new peer relationships encouraged in the curriculum revision were beneficial to learning. “And we are teaching each other as students too. It's not just the teacher teaching us which is really nice.”“My peers have work experience. And they are all in completely different random fields. And there are different lengths or experience. Like there are people who just started out and there are people who have been a nurse for 20 years. And different age ranges and family statuses. So it kind of supports the diversity of experiences that the students bring in.”
Applying New Learning Students found that they could apply the concepts to real-life situations. “The fact that you have to read and understand material to answer the discussions, so I have to take time to read and learn something new. If it is too easy, despite the fact that I want to learn, I will take the faster and easier way so I like that the material was easy to read, but I learned a lot.
Table 2 Survey results (scale 1–5; 1 – completely dissatisfied, 5 – completely satisfied) Question
n
Mean
SD
The concepts and outcomes for this course were defined and related to school of nursing competencies. The course activities and assignments enhanced my understanding of course concepts. The activities and assignments in the course units assisted me to achieve unit and course outcomes. Concept-based learning was an effective way to gain new knowledge and increase my nursing skills.
95 95 95 94
3.87 3.78 3.75 3.86
0.937 1.044 1.010 1.001
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“I feel that it helps prepare me for real life experiences rather than just being able to answer some questions on a test.”
Dissatisfaction Redundancy Redundancy was identified as a problem in both programs. Students perceived this as unnecessary busy work. “We have some repetition in assignments with several classes. Having to repeat assignments that are very similar in subject manner for several classes creates busy work.”“Some classes having the same outline and requiring the same homework, it is busy work at that time.” Some viewed redundancy as a positive characteristic. “Many of the concepts cross over between several classes and the learning is reinforced.”
Ineffective Pedagogy The students were not happy with sole use of lectures in the classroom, particularly in the RN-BSN program. “Because we want to take those discussions that are online and maybe tie them into the class. Maybe something like that instead of power point lectures.”“Sometimes there are concepts that don't seem to fit well with the other ones.”
Newness Students recognized the change in the focus of the curriculum and thought that it would require an adjustment by students. “I've noticed this year with the power point, like last year it seemed like they do a power point and we have a power point and we'd be following along taking notes. And then this year they're presenting on a power point but nobody's taking notes and we are all just listening. And I don't know if it's because it is online where we can look at it later. But I sit there and get nervous because I'm thinking should I be taking notes? But we're not having a test on it.”“Nursing school was a lot of memorizing and repetition. I think it can be a little frightening for students to be expected to know the bigger picture instead of focusing on the little details. I don't think the curriculum is a weakness, I think the change can be difficult for some students.”“It's just different and harder to study for. The way the test questions are worded makes it more difficult. For instance, I can explain a concept to you in detail but when asked to answer the test question there may not be enough detail and the options can be vague. It seems no matter how much more time I study I cannot do any better on the test. From a student standpoint memorization is a lot easier and less time consuming. However, I understand that the concepts are much more important learn.”
Teacher Characteristics Clearly, some faculty were more prepared and organized than others. “No teaching on the teacher's part. I feel like all I am doing is waiting for grades on papers that I have written.” “Don't know of any really problems with it. This class in particular was just poorly organized by the professor. I've spent half the time trying to figure out what was expected of me.”
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Mixed Results Faculty Relationships Some students reported feeling supported by the instructors, and some did not. “I think the concept-based curriculum is great but there is no teaching on the teacher's part. All they do is grade assignments.” “They're on your team. They want you to learn it because they want to give you their impression. It's like this is what I know because I've been through it now let me give this information to you.”
Group Work Students disagreed on the value of group work. “I also think that the use of groups for the online class is a little difficult to complete and do a good job on as it is hard to meet with group members.”“I don't know if what's been helping me has anything to do with new curriculum but I found that working in groups tends to be really helpful for me. I've been able to make some friends and we're all kind of going through the same things so we can help each other and remind each other of assignments and stuff.”
Discussion The curriculum revision team was interested in determining the impact of the newly revised curriculum change on students. The majority of the students indicated on the survey that they viewed the change to the new concept-based curriculum model positively (Table 2). Analysis of the qualitative data indicated that there were positive and negative impacts to students. Students experienced difficulty because of the newness, some redundancy, and specific faculty characteristics but also described positive experiences with the revised curriculum. Students were generally positive about the discussion assignments, enhanced critical thinking, the facilitation of learning, enhanced peer relationships, and application of new learning. Students found benefit in discussions that encouraged linking of concepts and higher level learning. They learned from the instructor and other students. They valued the interactions with diverse student groups. Students reported understanding of concepts, rather than memorization, and viewed this positively. They identified benefits of the new curriculum and felt that they were more prepared for real-life experiences. Negative aspects identified by students included redundancy. They objected to “busy work.” However, some students found redundancy to be a positive characteristic, specifically, when the concept was more challenging. They reported perceptions of ineffective pedagogy, such as over reliance on PowerPoint slides ®. They noted that the new curriculum seemed to be a difficult transition for some faculty. For example, students reported disorganization and confusing instruction. The students mentioned the effects of the adjustment of faculty to the curriculum on their learning. They also reported feeling insecure in the transition from memorization to critical thinking in concept-based learning. Students disagreed on the quality of teaching provided by the faculty. Some felt that faculty were disengaged and overwhelmed, whereas others reported faculty participating in more of a mentoring role. Another theme that emerged and students disagreed on was the topic of on-line group work. Some felt that group work made it difficult to complete assignments, whereas others found that group work improved their learning process.
Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002
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Limitations
Acknowledgments
A limitation for this study would be the small sample participating in the focus groups, although we achieved data saturation. Despite thorough instructions in the introductory e-mail, we may have had a larger sample size if we advertised in the school of nursing bulletin boards and had faculty mention the study in their classes. This may have also improved the number of questionnaire responses. Faculty considering involving students in evaluation of curriculum implementation should use multiple methods for recruitment. Students are busy, and single sources of information could be overlooked. The qualitative data from the surveys were included in the analysis, and this mitigated some of the issues with the small sample size. A second limitation was that data for the AS and the BSN in the ladder program were not analyzed separately. More than 90% of the AS students immediately transition to the BSN program following graduation. As a result, the majority of the RN-BSN students are novice nurses. However, there may have been differences in the two groups based on their level of program during the study. Although we invited all students to participate, some students had not been previous students in the SON but would have been exposed to traditional learning in their general education classes. The findings may be most applicable to ladder programs similar to our SON.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Recommendations The findings of the study reinforced that presentation of the material trumped value and quality. These findings are consistent with the model proposed by Alves and Raposo (2007). Faculty considering curriculum revision should focus on areas that impact course presentation. The courses need to be examined for consistency and unnecessary redundancy. Instructions and presentation of course material need to be clear, and discussions need to be well organized. Consideration should be given to utilizing innovative pedagogy, such as flipping the classroom. As students noted, there were some faculty who found the transition to a concept-based curriculum difficult. This reinforces the need for early and comprehensive faculty preparation and development. Unprepared faculty negatively impact the presentation of courses and, thus, reduce students' satisfaction. Conclusion The current study is one of the first of its kind to examine student satisfaction with implementation of a revised concept-based curriculum. The findings highlight both positive and negative perceptions of the curriculum. These findings emphasize the importance of course presentation and support and guidance to faculty when considering a curriculum revision.
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Please cite this article as: Gooder, V., & Cantwell, S., Student Experiences With a Newly Developed Concept-Based Curriculum, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.002