Journal of Nursing Education

Reflections on the Curriculum Revolution

Christine A Tanner, PhD, RN, FAAN

Abstract

It has rained for 5 days

running

the world is

a round puddle

of sunless water

where small islands

are only beginning

to cope

a young boy

in my garden

is bailing out water

from his flower patch

when I ask him why

he tells me

young seeds that have not seen sun

forget

and drown easily.

("Coping," by Audre Lorde)

The year 1986 marked the beginning of a contemporary movement that was proclaimed then as the Curriculum Revolution, and which has gathered some momentum over the last 4 years. I was fortunate enough to be part of a group of nurse educators who gathered together, first under the auspices of the Society for Research in Nursing Education, and later with the National League for Nursing, to consider the issues in nursing education and the changes necessary to launch nursing education into the next century. In this essay, I will share with you my recollections of the brief history of this revolution and my interpretation of the major themes that have emerged from the movement.

The Context for Change

At the time we began discussions of the "revolution," I had a sense of some despair over the state of nursing education and the issues that seemed to be chronically in the forefront of our dialogue. For the preceding 20 years, we had been caught up in the divisive and painful debates over entry into practice, titling, and licensing. I can remember stepping into an elevator at the 1985 NLN Convention, being greeted pleasantly by a colleague; our eyes shifted subtly (as they always do) to our name tags. She was from an associate degree program, and I from baccalaureate program. We fell into a difficult silence, which I attributed to the more angry debates that had just occurred on the convention floor. I felt the gulf between us to be so wide that I wondered if we could ever bridge it to take up again some of our shared concerns as women and as nurses.

While we, as a discipline, argued over entry into practice, the health-care scene was dramatically changing. Prospective payment had altered the face of hospital nursing practice and opened up new demands for nursing services in home care and long-term care. New technology, seemingly introduced daily, also continued to transform nursing practice. These shifts in acute care were accompanied by growing public awareness of and dissatisfaction with the American model of health care; the narrow, biomedical perspective that overlooks major societal conditions that lead to disease, such as poverty, homelessness, and environmental pollution. The limited resources for long-term care, societal prejudices toward disenfranchised groups, and societal ills reflected in drug abuse showed up most acutely as the nation began to face the AIDS epidemic. There were growing concerns about the graying of America and the inadequacy of the biomedical model to address the long-term health-care needs of the elderly. While we spoke of health promotion, Congress was arguing over how much of the tax dollar would go into support for the tobacco industry. It was becoming increasingly clear that health care in this country was grossly inadequate, and the question facing nurse educators was - and still is - are graduates from our programs going to be educated to do anything different?

This was the context for the proclamation of a curriculum revolution. Never before in our history have there been such compelling reasons for serious study of our educational programs and for major reform. We continue to struggle with our content-overloaded curricula that attempt simultaneously to "prepare" nurses to practice in a biomedically oriented disease-care…

It has rained for 5 days

running

the world is

a round puddle

of sunless water

where small islands

are only beginning

to cope

a young boy

in my garden

is bailing out water

from his flower patch

when I ask him why

he tells me

young seeds that have not seen sun

forget

and drown easily.

("Coping," by Audre Lorde)

The year 1986 marked the beginning of a contemporary movement that was proclaimed then as the Curriculum Revolution, and which has gathered some momentum over the last 4 years. I was fortunate enough to be part of a group of nurse educators who gathered together, first under the auspices of the Society for Research in Nursing Education, and later with the National League for Nursing, to consider the issues in nursing education and the changes necessary to launch nursing education into the next century. In this essay, I will share with you my recollections of the brief history of this revolution and my interpretation of the major themes that have emerged from the movement.

The Context for Change

At the time we began discussions of the "revolution," I had a sense of some despair over the state of nursing education and the issues that seemed to be chronically in the forefront of our dialogue. For the preceding 20 years, we had been caught up in the divisive and painful debates over entry into practice, titling, and licensing. I can remember stepping into an elevator at the 1985 NLN Convention, being greeted pleasantly by a colleague; our eyes shifted subtly (as they always do) to our name tags. She was from an associate degree program, and I from baccalaureate program. We fell into a difficult silence, which I attributed to the more angry debates that had just occurred on the convention floor. I felt the gulf between us to be so wide that I wondered if we could ever bridge it to take up again some of our shared concerns as women and as nurses.

While we, as a discipline, argued over entry into practice, the health-care scene was dramatically changing. Prospective payment had altered the face of hospital nursing practice and opened up new demands for nursing services in home care and long-term care. New technology, seemingly introduced daily, also continued to transform nursing practice. These shifts in acute care were accompanied by growing public awareness of and dissatisfaction with the American model of health care; the narrow, biomedical perspective that overlooks major societal conditions that lead to disease, such as poverty, homelessness, and environmental pollution. The limited resources for long-term care, societal prejudices toward disenfranchised groups, and societal ills reflected in drug abuse showed up most acutely as the nation began to face the AIDS epidemic. There were growing concerns about the graying of America and the inadequacy of the biomedical model to address the long-term health-care needs of the elderly. While we spoke of health promotion, Congress was arguing over how much of the tax dollar would go into support for the tobacco industry. It was becoming increasingly clear that health care in this country was grossly inadequate, and the question facing nurse educators was - and still is - are graduates from our programs going to be educated to do anything different?

This was the context for the proclamation of a curriculum revolution. Never before in our history have there been such compelling reasons for serious study of our educational programs and for major reform. We continue to struggle with our content-overloaded curricula that attempt simultaneously to "prepare" nurses to practice in a biomedically oriented disease-care system and to educate nurses to be responsible health-care professionals committed to the social changes necessary for health promotion and disease prevention. And we continue with an institutionalized commitment to a rational-technical model of education that may no longer serve us well for educating caring and critically thinking nurses.

The curriculum revolution was an invitation to nurse educators to consider both the issues in the health care system and the dilemmas we encounter in our educational programs. The 1987 National Conference on Nursing Education was devoted entirely to the theme "Curriculum Revolution: A Mandate for Change." Since then, two additional national conferences and several interim meetings of conference faculty and planners have brought into view several major themes and values of the Curriculum Revolution.

The term "revolution" was initially adopted for its meaning as "a sudden or momentous change in any situation." It also carries with it the meaning implied in Kuhn's writings on scientific revolutions: "those noncumulative developmental episodes in which an older paradigm is replaced in whole or in part by an incompatible new one" (Kuhn, 1970, p. 62). Although Kuhn implied at least 21 different meanings for his term "paradigm," one fairly consistent usage is that of a world view, a way of understanding a phenomenon that is implicitly or explicitly agreed to by a community of scholars (Masterman, 1970). Hence, a revolution in this sense would occur when the community of nurse educators tacitly or explicitly agrees to a new world view of our educational practices.

Defending his use of the revolution metaphor, Kuhn writes of the parallelism between political and scientific development:

Political revolutions are inaugurated by a growing sense, often restricted to a segment of the political community, that existing institutions have ceased adequately to meet problems posed by an environment that they have, in part, created. In much the same way, scientific revolutions, are inaugurated by a growing sense, again often restricted to a narrow subdivision of the scientific community, that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way. In both political and scientific development, the sense of malfunction that can lead to crisis is prerequisite to revolution (Kuhn, 1970, p. 62).

The extended parallel to nursing education must be apparent. There is a growing sense of malfunction in the continued use of the behavioral model of education for nursing. The solutions to content overload do not seem to He in redefining the conceptual framework and behavioral outcomes, then reorganizing and resequencing the tremendous volume of content. The solution lies elsewhere. Although a new paradigm has not yet emerged, several alternative perspectives have been advanced, debated, and discussed.

Another controversy surrounding the use of the term revolution is the extent to which dramatic and major change is needed. Some have argued that so far in the discussion, nothing is new at all. Some have held that the behavioral model has served us well, and what is needed are mere innovations (Wolff-Willetts, 1989). Goldman (1988) writing of the revolution in public education, suggests that degrees of change may be conceptualized as a continuum from innovations, to a reform movement to a revolution. His distinctions among the three are useful:

Innovation and reform operate within conventional boundaries; revolutions challenge the older assumptions and rules, often seeking new ends and using new means. Attempting to improve a given situation, innovations require little change in our social structure or in the way we think about education; practitioners find a better technique to do something. Reforms usually result from some shift in the social structure which necessitates changes in the means to achieve agreed upon ends. Revolutions usually arise from major social changes, often project new purposes, and require a reconceptualization to explain and justify the new situation (pp. 47 - 48).

Papers presented at the conferences and published in a series by the National League for Nursing (NLN, 1988; 1989, in press), reflect all three levels of change. But the major thrust has been on the order of revolution as defined by Goldman: alternative conceptions of the educational process, reflective of major social changes, particularly the crisis in health care, and directed toward new ends.

The Major Themes of the Curriculum Revolution

From the last three conferences on nursing education, the conference proceedings, discussion and debate among my colleagues who have served as conference planners and faculty, have emerged a number of themes and core values undergirding the curriculum revolution. This is not intended to be an exhaustive list of core concepts, nor are these themes mutually exclusive. Nor does the discussion present a conceptually ordered framework for the revolution, but rather it is an effort to explicate the themes and values about new paradigm educational processes and about the nature of the revolution itself.

Social Responsibility

We have kept before us, as a central concern of the curriculum revolution, the need for transformation of the health-care system. We know of the powerful relationship between poverty and disease and we have begun to understand the narrow and contorted view of the biomedical model that dominates health care today (Moccia, 1988). We know that health promotion depends very little on access to medical care, but rather healthier circumstances of living, such as shelter, adequate nutrition, and clean water and air. We have experiences with community nursing programs that point to the success of community building and activism in reducing infant mortality and incidence of disease. In a resolution passed unanimously at the NLN Biennial Convention, values for socially responsible curricula were evident. The resolution called for curricular innovations that reflect:

enhancement of caring practices through faculty-student and faculty-to-faculty relationships that are egalitarian and characterized by cooperation and community building;

social values that recognize the multi-cultural, multiracial, and growing diversity of both individual and family lifestyles in our society;

learning experiences that incorporate critique of the current health-care system and analysis of the present and future health needs of the population as the basis for transforming the health care system;

substantive contact with, or participation by, persons at health risk. (National League for Nursing, 1989).

The Centrality of Caring

In both the processes of education and the dialogue and debate on the revolution, participants have sought to reclaim caring as a core value. Caring is not viewed as the antithesis to the scientific process of nursing, as implied in a recent editorial (Barnum, 1990), but rather central to it. It is viewed as the ". . .most basic mode of being. Caring means that people, interpersonal concerns and things matter" (Benner & Wrubel, 1989, p.l). Caring is what allows the nurse, or the teacher, to understand and to act on the concerns and issues of their clientele.

An Interpretive Stance

By an interpretive stance, I mean the intent to unveil, understand and criticize beliefs and assumptions that guide our practices, but which may be covered over by formal, theories, rules, or procedures. It is through interpretation that the good in our practice is uncovered and that new possibilities are opened up.

There are a number of published works that illustrate this point. Probably one of the most influential in my work has been the writing of Schon (1983). He analyzed the practice of a number of professions and criticized the dominant understanding of the practice. He pointed to assumptions implicit in the rational-technical epistemology of practice, specifically that professional practice is the mere application of scientific knowledge to technical problem solving in practice. To understand this as an assumption rather than a truth was emancipatory for me. This positivist epistemology of practice is clearly a view that has dominated nursing and nursing education in our adherence to nursing process as the model for our practice (Henderson, 1982; Tanner, 1986). Schon also pointed out how this assumption has led to a hierarchical ordering of higher education in the professions from the highly valued basic sciences to the lesser valued applied sciences to the "messy" aspects of professional practice. He illustrated ways in which the assumptions of this epistemology simply cannot hold up in the complex and uncertain field of professional practice. While I may not agree entirely with his new epistemology of practice, his analysis opened up new possibilities for considering the ways in which we educate our students.

There are numerous other illustrations of works that reveal for us meanings and assumptions in our everyday practices. Kleinman and associates (1978) pointed to medicocentri sm and the narrow biomedical view that focuses on disease rather than illness. Systematic gender bias in our understanding of moral and cognitive development has been unveiled through the interpretive works of Gilligan (1982) and Belenky, Clinchy, Goldberger, and Tarule (1986). The provocative analysis of the so-called banking concept of education offered by Freiré (1970) opened up possibilities of transformed power relationships between students and teachers. In nursing practice, Benner (1984) has pointed to clinical knowledge development that has been covered over by the cultural supremacy of theoretical knowledge. In nursing education, Bevis and Watson (1989), Diekelmann (1988), Diekelmann, Allen, and Tanner, (1989) and Allen (in press) have pointed out for us the taken-for-granted meanings of the behavioral model that we may no longer wish to accept.

The curriculum revolution, in one sense, then, is an effort to uncover for us the assumptions and meanings that are part of our every day practice as educators, and to open up new possibilities for us.

Theoretical Pluralism

Another related aspect of the curriculum revolution is emancipation from singular and narrow views of what constitutes education. The behavioral model, also variously referred to as the rational-technical model or the Tyler model, has limited our vision of what counts as quality nursing education. Any model, of course, necessarily limits one's view of their practice. But the behavioral model had become so institutionalized through professionally acclaimed books on curriculum development, and accreditation and state board approval standards, that the possibilities for other approaches to nursing education could not be actively considered and, in fact, have been marginalized. Participants in the revolution have to create the possibility for pluralism. We have heard voices representing feminist pedagogy, Marxist critical social theory, cognitive theory, Heideggerian phenomenology, and humanistic pedagogy. If the analogy of the curriculum revolution to a scientific revolution holds, it is likely that a new model and world view will replace the old. And this possibility presents a major dilemma as we strive for change; none of us wish to adopt a new equally enslaving model of education, but rather encourage the diversity necessary to achieve our goals of responding to our social responsibility as a health profession and maintaining local control over curricular decision making.

The commitment to theoretical pluralism creates another dilemma in the revolution. Standards of quality education have traditionally been theory-laden, and many of us question the possibility of theory-neutral standards for accreditation or approval of schools of nursing. Yet, the solution to the issues facing both education and the health-care system requires experimentation from multiple theoretical perspectives. A challenge before us is the development of meaningful quality standards that retain the value for pluralism and encourage experimentation.

The Primacy of the Teacher-Student Relationship

Interestingly, a common theme across most of the non-behavioral theoretical perspectives has been the primacy of the teacher-student relationship. In the humanistic-educative model offered by Bevis (1988) and Murray (1989), curriculum is defined as ". . .the transactions and interactions that occur between student and teacher and among students with the intent that learning take place" (p. 190). Hence, in this view, the teacher student relationship is the curriculum. A phenomenological model, presented by Diekelmann and associates, (1989), requires a transformed relationship between teacher and student, to open up the possibility for learning from one another through meaningful dialogue. In feminist pedagogy (Wheeler, 1989; Chinn, 1989), the traditional power relationships between teacher and student are challenged and transformed to an egalitarian, shared responsibility for learning.

In addition to its theoretical relevance, the teacherstudent relationship is central to the revolution in a more fundamental way. The revolution is viewed as a transformation in one's world view and learning new ways of relating to students both constitutes a transformation in world view and facilitates this transformation. For example, once a faculty member begins to shift to a more egalitarian relationship in which a student's life and work experiences are valued, then some aspects of the behavioral model become untenable; it is no longer possible to embrace the notion of specifying all important objectives ahead of time.

Nothing could be more challenging to the traditional paradigm, specifically the teacher student relationship, than the notion of teachers as learners. This notion was offered by Freiré (1970) in his provocative critique of traditional power relationships between students and teachers in what he termed the banking concept of education. (In the banking concept, knowledge is deposited by the all-knowing teacher, into the students who are passive receptacles). He writes of the transformed teacherstudent relationship in what he terms "problem-posing education":

Through dialogue, the teacher-of-the-students and the students-of-the-teacher cease to exist and a new term emerges: teacher-student with students-teachers. The teacher is no longer merely the-one-who-teachers, but one who is himself taught in dialogue with the students, who in turn while being taught also teach. They become jointly responsible for a process in which all grow (p. 67).

This kind of relationship is clear in the writings of Adler (1988) on public education. It shows up in the work of Belenky and associates (1987) in their study of women's experiences in higher education, and in their conception of the teacher as midwife. And it is a central theme in the writings on the curriculum revolution in nursing (Chinn, 1989; Diekelmann et al; 1989; Bevis and Watson, 1989).

Summary

For me, the curriculum revolution means opening up new possibilities for the ways in which we educate our students. It means a new consciousness about the place of nursing in responding to the health-care needs of our nation. It means coming to terms with the conflicts and contradictions that we as educators have felt for at least the last decade; these conflicts lie in our understanding of the crisis in health care and the demands on us to educate caring, critically thinking nurses who can safely practice in both today's world of high-tech disease care and tomorrow's world of true health care. The curriculum revolution means healing our wounds from the divisive issues of the past, and joining together in charting our future.

References

  • Adler, M.J. (1988). Reforming education: The opening of the American mind. New York, NY: MacMillan.
  • Allen, D. (In press). Critical social theory in nursing education. Curriculum revolution: Redefining the student-teacher relationship. New York, NY: National League for Nursing.
  • Barnum, B. (1990). On nursing. Nursing and Health Care, il(5):227.
  • Belenky, M.P., Clinchy, B.M., Goldberger, N.R., & Tarule, J.M. (1986). Women's ways of knowing. New York, NY: Basic Books.
  • Benner, P. (1984). From novice to expert: Power and excellence in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
  • Benner, P. & Wrubel, J. (1989). The primacy of caring: Stress and coding in health and illness. Menlo Park, CA: Addison-Wesley.
  • Bevis, E.O. & Watson, J. (1989). Toward a caring curriculum: A new pedagogy for nursing. New York, NY: National League for Nursing. No. 15-2278.
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  • Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press.
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  • Greene, M. (1978). Landscapes of learning. New York, NY: Teachers' College.
  • Henderson, V. (1982). Nursing process: Is the title right? Journal of Advanced Nursing.
  • Kleinman, A., Eisenberg, L, & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and crosscultural research. Annals of Internal Medicine, 88, 251-278.
  • Kuhn, T.S. (1970). The structure of scientific revolutions, 2nd ed. Chicago, IL: University of Chicago Press.
  • Lorde, A. (1978). Coping. The black unicorn. New York, NY: WW. Norton.
  • Masterman, M. (1970). The nature of a paradigm. In Lakatos, I. & Musirave, A. (Eds.). Criticism and the growth of knowledge. Cambridge, MA: Cambridge University Press, pp. 59-89.
  • Moccia, P. (1988). Curriculum revolution: An agenda for change. In Curriculum revolution: Mandate for change. New York: National League for Nursing (pp.53-64). Pub. No. 15-2224.
  • Schon, D.A. (1983). The reflective practitioner. New York, NY: Basic Books.
  • Tanner, C. (1986). The nursing care plan as an educational method: Ritual or reason? Nurse Educator.
  • Wheeler, C. & Chinn, P. (1989). Peace and power: A handbook of feminist process, 2nd ed. New York, NY: National League for Nursing.
  • Wolff-Willette, V. (1989). Paper presented at the Fifth Annual Nurse Educator Conference.

10.3928/0148-4834-19900901-04

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