To date, much of the curriculum literature in nursing has been devoted to analysis of the strengths and weaknesses of programs which are considered to be "integrated" in the sense that they depart from the traditional medical model for curriculum organization. A review of this literature indicates that the debate is based on an artificial dichotomy between integrated and nonintegrated curricula. The survey reported here is predicated on the assumption that most schools, whether they advertise their programs as integrated or not, utilize some scheme for organizing the curriculum to deliver a coherent program. The purpose of the study was to identify models employed to organize curricula and estimate their frequency of use.
Tyler1 suggested three classic principles to consider in curriculum organization: Continuity, Sequence, and Integration. According to Tyler, Continuity refers to the "recurring emphasis" of "particular elements" in the learner's experience. Sequence refers to the "breadth and depth of the learner's development." Integration reflects "the learner's increased unity of behavior in relating to the elements involved."1 In the early 60s there was much debate regarding whether integration could be achieved within a program or whether it should only reflect the psychological process occurring cognitively in the student's individual development.
Historically, the organization approaches used in curriculum reflect at least six patterns: (1) Subject Matter, (2) Core, (3) Principles, (4) Behavioral Systems, (5) Concepts, and (6) Nursing Models. The original pattern followed a subject matter organization built around the clinical specialization such as Medical, Surgical, and Psychiatry. Core content began to be identified as Abdellah,2 Henderson,' and others began to identify key nursing problems. Nordmark and Rohweder* identified science principles relevant to nursing. For a time this was a key organization focus. Behavioral systems became popular as an organizational approach in the early 1970s.5'6 Johnson's behavioral systems model and the behavioral subsystems model proposed by Campbell et al. are key examples of the application of this organizational approach in nursing. Concepts have been a recent development as an organizational approach to content.' One of the most recent developments has been aimed at derivation of a model which uses knowledge and content derived from other disciplines but synthesizes it in such a way that it becomes uniquely nursing.10'" The accompanying diagram attempts to represent some of the major components of curriculum models which have been formulated over the past two decades (Figure).
Integration has become a key word which has a bearing on program organization. Integration related to curriculum usually refers to the interrelationships of particular elements within a given program. It also may refer to the blending12 of particular subject areas such as nutrition, pharmacology, and biological and behavioral science components"'14 into a theoretical course on nursing practice. Some programs use nursing process or other organizing theme as an integration point. Integrated programs designating courses as Nursing I, II, HI, etc., are sometimes distinguished from "block" program s which specify medical, surgical, or pediatric courses.
In order to determine which organizing approaches were employed most frequently, the writers surveyed selected four-year programs to identify some of the ways they approached curriculum organization, regardless of whether they identified their program as an integrated curriculum or not. Questionnaires were sent to a 50% random sample of National League for Nursing accredited baccalaureate programs. Ninety-one of 144 forms were received, a 61% return. The questionnaire consisted of three questions. The first was: "Which of the following methods of program organization would be most characteristic of your school's undergraduate program? If two descriptions are equally appropriate, you may check more than one category." The question was followed by eig h t ca tegories: 1) concept s a nd/or th read s; 2) nursing principles; 3) organizing theme, e.g., Erickson's stages, family or socioculturel organization; 4) behavioral systems; 5) disease orientation, e.g., heart disorder; 6) nursing process; 7) body systems orientation, e.g., circulatory system; and 8) other. Other than the examples which were given for three choices, no attempt was made to define the terms which were used. The investigators believed that it would be most efficient to allow the program directors to interpret the terms as they saw fit, even if this meant some loss of precision in the data obtained. The results from this question are given in Table 1. It is clear from the summarized data that the overwhelming majority of schools attempt to integrate curriculum components through the use of some combination of concepts, threads, and nursing process orientation.
ALTERNATIVE MODELS FOR BACCALAUREATE CURRICULA
Most of the program directors indicated that their schools used more than one method of integrating content. For those who selected two categories, 20 listed a combination of nursing process and concepts and threads, Eight listed combinations that were employed infrequently.
Twenty-one respondents checked three categories. Of this group, 11 checked concepts and threads, organizing theme and nursing process. No other combination was selected more than three times. All 21 of the tripart combinations included concepts and threads, and all except one included nursing process.
The second question asked program directors to indicate the number of courses which used each organizing approach selected. The responses indicated that most programs employed the organizational methods for all courses. Few programs used different organizational approaches for different blocks of courses.
The main differences in curriculum design were revealed in response to the last item in the survey. This item requested that program directors "Please give one or more examples to further describe the method(s) of curriculum organization described above, e.g., 'health-illness' or 'life cycle' might be cited to illustrate organizing concepts and threads." The responses to this item indicated that the major differences in curriculum design were related to complexity of organization and the selection of specific topics as organizing features. Although the item did not request the program directors to do anything more than list examples, many gave detailed descriptions of their curriculum organizations. In addition, a number of the examples were repeated many times, suggesting that some concepts or threads were used much more frequently than others. Of those program directors who indicated a complete curriculum scheme, the use of four curriculum components was common. The following list illustrates some of these examples:
Example 1: Four Threads
Socia liza tion-Prof essionaliza tion
Man: Individual, Family Community, Society
Example 2: Four Concepts and Threads
Clients System Behavioral Responses
Health Care Delivery System
Example 3: Four Strands
Example 4: Four Models
Nursing process occupies a position in curricular organization which seems to be unique. It is an integral part of most programs. In some curricula it provides an overall organizational focus. In others it has the status of a major concept or thread. The only other construct which enjoys a similar level of popularity is the healthillness continuum or its variants (wellnessillness, levels of wellness, high level wellness). Nursing process was mentioned as a concept or thread by 11 program directors. When this figure is added to the 52 who listed it as a curricular organizational focus, it becomes apparent that almost all of the programs used nursing process in some way. Health-illness was listed as a concept or thread by 42 program directors. Many other concepts and threads were mentioned as examples by the program directors, but they were not listed nearly as often as nursing process or health-illness. Fourteen respondents listed life cycle, and 11 listed stress-adaptation, socializationprofessiona liza tion, or man-environment. Ten listed individual family-community. Another group of concepts and threads received at least five selections. These were holistic man, change, interaction or communication, research, leadership, and growth and development. Over 50 different topics weTe listed as concepts and threads by fewer than five program directors. The full list of examples is given in Table 2.
The "other" category was only checked eight times by program directors. In four cases, only the "other" category was checked. One of these programs was using Roy's adaptation model, The second was based on five interactive components. A health-illness model was utilized for the third program based on "problems of contemporary health and illness with emphasis on health maintenance and illness prevention (population level as well as personal health services)." The program director of the fourth school stated that the curriculum was based on a series of broad, base-line courses (pathophysiology, psychosocial nursing, etc.) followed by the traditional clinical specialties.
FREQUENCY OF USE OF METHODS INTEGRATiNG CURRICULAR CONTENT NUMBER IN THE SAMPLE IS 91
From these data it is evident that concepts are a major choice for a curricular organizational approach. Redman15 has suggested that integrated curricula pose problems because some of the old medical models have ". . .patched [with] so many nursing 'threads' or concepts. . ." that they fail to be coherent. In light of the evident popularity of this mode of curricular integration, the desirability of theapproach should be considered. The ideal and the reality should both be discussed. Given broad and easily generalizable concepts such as nursing process and health-illness it would appear to be possible to design a curriculum in which most of the course objectives are related to the concepts in a systematic fashion. If so, Redman's criticism does not necessarily hold true. In actuality, it is likely that some faculty members will support pet concepts even after the conceptual framework has been agreed upon. In addition, there is a general tendency to seek ways of coping with "loose ends" in the curriculum design, either by ignoring the conceptual framework for a period of time (perhaps to discuss a topic such as biochemical implications of burns) or by adding a new "patch" to the curriculum, until the curriculum design becomes unwieldy. These phenomena are not necessarily associated only with an approach based on concepts and threads. The implementation of a comprehensive nursing model also requires strong leadership and close monitoring, especially when aspects of the model may conflict with the conditions of nursing practice,
A conceptual approach need not represent a haphazard addition to the old content. If concepts and threads of those concepts are identified carefully, they can be introduced and expanded at successively meaningful intervals. The degree to which such introductions of concepts facilitate synthesis of thought processing depends on how well succeeding learning experiences reinforce each concept and related thread.
There is no doubt that simply introducing concepts in no way facilitates the nursing student's learning experiences. The choice of concepts is critical since each should be considered pertinent and applicable only if it serves to assist the student to more effectively develop and implement nursing care. Concepts apparently have served to assist a number of faculties in achieving this since the majority have indicated they are using this approach. Text titles also tend to reflect this emphasis, since a large number of them include the word "concepts" in their titles, e.g.. Concepts Basic to Nursing.""
EXAMPLES OF CONCEPTS. THREADS. THEMES AND OTHER ORGANIZATIONAL APPROACHES
The curriculum design should facilitate the sequential development of curriculum content. Styles appealed to the schools to remember that their basic objective is "...with economy and efficiency to assist the learner to discern and use relationships among the knowledges, skills, and values learned..."17 A sequential development would facilitate this objective. If this dictum were modeled constantly there would be less inclination to pursue the popular focus of the moment. Since nursing builds on both behavioral and biological sciences, faculty are naturally vulnerable to a variety of trendy approaches originating in any of these science areas. The use of a behavioral systems approach is an example of a trend from science which has been adapted into nursing curricula without enough discussion given to some of the difficulties this might pose in clinical practice settings. The initial thought, "That would be good to apply to our nursing program, too!" is appealing, but what is applicable in a given science area may be far from effective in a nursing program.
The question of the number of concepts which faculty can use effectively in program design and implementation is not definitely determined. However, parsimony should be a criterion for program development. One, two, and possibly three, concepts might be utilized effectively in interrelating details and entities. But if very many more are added even if the main threads can be followed, some of the strands will be lost in the pattern. Most teachers (or weavers) become confused when the materials being used for the design become so cumbersome that following the initial pattern becomes difficult. Just fitting the threads together becomes such a task that the effect of such a mosiac may become lost. And if the teachers have difficulty, the learner certainly will too. Following lots of small concepts is bound to take more time and thus be less efficient than following only one or two major ones.
The differentiation of concepts, threads, and strands is probably less critical than it might seem. Since a good argument could be made for considering nursing process as a concept, thread, or strand as it appears at different points in curriculum design, it is not surprising that many of the respondents tended to use the terms interchangeably. Health-illness is one area which has been treated as a concept, thread, or strand. Perhaps no focus is always a concept or always a strand, but rather modified over time in terms of what the student is expected to do with it.
As is apparent in this survey, no one approach tocurriculum organization seems universally satisfactory even within the narrow confines of the US. However, the trend is to identify concepts as a major approach. The reason typically given for the use of concepts is that they serve to unify or interrelate details. Because nursing is broad and interfaces with so many sciences and related specializations, it is understandable that some way to bridge some of the discrete islands is both desirable and needful. This may explain the present popularity of the use of concepts in organizational design.
- 1. Tyler RW: Basic Principles of Curriculum and Instruction. Chicago, The University of Chicago Press, 1949.
- 2. Abdellah F, Beland IL, Martin A et al: PatientCentered Approaches Io Nursing. New York, The Macmillan Co, 1961.
- 3. Henderson V: The Nature of Nursing. New York, The Macmillan Company, 1966.
- 4. Nordmark MT, Roh weder AW: Science Principia Applied to Nursing. Philadelphia, JB Lippincott Company, 1959.
- 5. vonBertalanffy, L: General System Theory, New York, George Braziller, 1968.
- 6. Finch ): Systems analysis: A logical approach to professional nursing care. Nurs Forum, 8:176-190, 1969.
- 7. Johnson D: One conceptual mode! of nursing. Paper presented Vanderbilt University, Nashville, Tennessee, 1968.
- 8. Campbell MA, Cruise MJ, Murakami TR: A model for nursing: University of British Columbia School of Nursing, Nurs Papers,'8:S-9, 1976.
- 9. O'Kelly LE, McKi nney G: A conceptual mode! for medical surgical nursing. Nurs Outlook 19:731736, 1971.
- 10. Roy C Sr: Adaptation: Implications for curriculum change. Nurs Outlook 21:163-168, 1973.
- 11. Chrisman M, Riehl J: The systems-developmental stress model, in Riehl JP, Roy CSr (eds.l: Conceptual Models for Nursing Practice. New York, Appleton-Century-Crofts, 1974, pp 247-266.
- 12. Torres G: Educational trends and the integrated approach to curriculum, in Faculty-Curriculum Development, Part 4. Unifying the Curriculum - The Integrated Approach. (Publication No. I5-ISS2) New York, National League for Nursing, 1974.
- 13. Branch M: Models for introducing cultural diversity in nursing curricula. iNurs Educ 15:7-13, 1976.
- 14. Garner VM, Merrill E: A model for development and implementation of cultural content in the nursing curriculum. I Nurs Educ 15:30-34, March 1976.
- 15. Redman BK: On problems with integrated curricula in nursing. / Nurs Educ 78:26-29, June 1978.
- 16. Mitchell, PH: Concepts Basic to Nursing. New York, McGraw-Hill Book Company, 1977.
- 17. Styles MM: In the name of integration. Nur Outlook 24:738-744, 1976.
- 18. Orem DE: Nursing: Concepts of Practice. New York, McGraw-Hill Book Company, 1971.
FREQUENCY OF USE OF METHODS INTEGRATiNG CURRICULAR CONTENT NUMBER IN THE SAMPLE IS 91
EXAMPLES OF CONCEPTS. THREADS. THEMES AND OTHER ORGANIZATIONAL APPROACHES