Embarking upon curriculum development or curriculum revision can be a formidable task. At the same time, such an experience can be intellectually exciting as developers discover and explore the various tenets underlying their intended curriculum's process and product. This challenge is magnified when the task involves development of a broad, generic, curricular framework aimed toward a national audience. Such was the case for an ad hoc educational committee (AHEC) formed by the board members of the National Organization of Nurse Practitioner Faculties (NONPF). In 1988, this AHEC was charged with reviewing and developing curricular guidelines for nurse practitioner (NP) education. The aim was to offer updated guidelines that could be used by a broad contingency of NP !acuities for the purpose of NP curriculum development or revision. This article highlights both the process by which this challenge was mounted and the resultant Advanced Nursing Practice: Nurse Practitioner Curriculum Guidelines (NPCG) (Zimmer, Brykczynski, Martin, Newberry, Price, & Warren, 1990).
Impetus Behind the New Curricular Guidelines
To understand the impetus behind developing new curricular guidelines for NP education, it seems useful to highlight the history of the NP role itself The NP role originated with Henry Silver, MD, and Loretta Ford, PhD, RN, in Denver, in 1965. The inception of the role was a response to increased awareness of inequities in access to health care. The purpose of the project was to determine whether nurses could be trained to expand the scope of their practice to provide better and more widely available health care for children" (Mauksch, 1978).
Since that time, however, the NP role has expanded to include other patient populations such as family, women's health, geriatrics, and occupational health with the NP scope of services broadening to include full, comprehensive health services to clients.
Over the past 25 years, expansion of the NP role has changed the educational processes associated with it. With the initial interest and popularity, a plethora of NP certificate programs emerged, most often originating through existing continuing education systems. Until 10 years ago, federal funding supported many of these programs. Indeed, these programs made it possible for the occurrence of a "critical mass" to have an impact on the health care marketplace. By 1990, there were approximately 25,000 nurses prepared as NPs.
The popularity and acceptance of the NP role was so quickly and firmly implanted within the nursing profession that, within 10 years of its inception, the American Nurses Association (ANA) was prompted to formally define this advanced practice role and to establish guidelines for the continuing education programs preparing adult and family nurse practitioners (ANA, 1975). In addition, the ANA also developed certification examinations for the NP role in a variety of areas (ANA, 1990).
When it became apparent that the role was not a passing trend in health care, the first comprehensive "Guidelines for Family Nurse Practitioner Curriculum Planning" was developed by the National Task Force on FNP Curriculum and Evaluation (1980) through the support of the Robert Wood Johnson Foundation. This compilation was a detailed presentation of the technical information and expanded skills required of nurses who chose the NP role.
NONPFs proposed guidelines for NP curricula were not intended to replace any previous work, but to build upon those developments while accounting for the changes in NP practice and education that have occurred since the mid1970s. Vast societal changes, and changes within nursing have occurred during the past 25 years. Changes within the NP arena specifically have mandated a new look at NP curricula. These changes include: (Da shift in the setting and funding of NP education, i.e., from continuing education and/or certificate programs to academic studies (graduate level); (2) documented research on the effectiveness and process of the NP role; and (3) clarification of content required for advanced practice in nursing.
The shift of NP education from continuing education and certificate programs into graduate level education has been documented by Geolot (1987). By tracking federal funding patterns, Geolot reported "... in fiscal year 1976, 70.6% of the funded (federal) grants were at the certificate level and 23.55% were at the master's level . . . [By] FY 1985, [master's programs] made up 81.1% of the total and fewer than 18% of the projects were at the certificate level" (p. 32-33).
This movement toward master's preparation has gained sufficient support to prompt the ANA to require master's preparation in order to apply for ANA certification examinations. This application criteria is to take effect by 1992 (ANA, 1990). This requirement does not mandate that the NP education, per se, has to occur at the master's level, but NPs seeking certification will have to provide evidence of advanced education (master's or higher degree) in nursing.
In addition, some states with requirements for an advanced practice license for NPs are requiring that the applicant seeking licensure provide evidence of completing NP education at the master's level. It should be noted, however, that not all states require this mode of NP preparation, nor do all states require that NPs provide evidence of ANA certification. Yet, there does seem to be a trend toward establishing stringent criteria for NP practice (as for any health profession), and it seems likely that the highest professional standards will be carefully considered when establishing scope of practice statutes (Pearson, 1990).
Another factor highlighting the need for a new look at NP curricula is the availability of research about the NP role. In contrast to the 1960s and early 1970s, the literature is now fairly replete in reviewing the NP role in terms of cost-effectiveness (McGrath, 1990; Feldman, Ventura, & Crosby, 1987), patient satisfaction (Kulal & Clever, 1974), competency of care delivery (Office of Technology Assessment, 1986; Spitzer et al., 1974), and actual NP care delivery processes (Billingsley, 1986). In all of these areas, there are positive reports of the overall effectiveness and acceptance of the NP role (Johnson & Freeborn, 1986). In addition, NPs have generated three professional journals (Nurse Practitioner, Journal of the American Academy of Nurse Practitioners, and Nurse Practitioner Forum) as media for NP^ clinical concerns and research. Having this documentation of what NPs do and their perceptions of their education and practice makes it somewhat easier to identify a collective educational core of information needed and used by NPs.
The third change has been the clarification of the advanced practice role. In the beginning, NP programs were largely identified by their assumption of those technical skills usually associated with physician practice, in particular the incorporation of history-taking and physical examination skills. At that time, educational content focused largely on recognition and management/referral for treatment of disease. This actually raised some controversy for a time as some nurses took issue with the NP role and saw it as little more than "physician extender" rather than as an expansion of the health care role of the nurse.
Today, it is not unusual to find components of the skills of history-taking and physical examination being taught at the undergraduate level. It has become increasingly clear that, in addition to basic nursing education, there is a need for a sufficiently sophisticated and competitive advanced practice level that is based on theory and research. The new NP graduate must quickly assume a position as an accountable member of a broad, interdisciplinary health team. NP curricula for the 1990s and the new millennium need to reflect this content in addition to a strong clinical base.
Developing NP Curricular Guidelines
The traditional components of any curriculum include philosophy and assumptions, characteristics of the graduate, conceptual framework, content and learning experiences to be included, and evaluation. The AHEC approached the development of the new curricular guidelines by attending to these same components as they apply to NP education. One exception was the component of evaluation, which was beyond the scope of the AHEC original task. Too, curriculum evaluation, per se, is really within the purview of individual faculties as they examine their specific programs and resources. An evaluative follow-up to the NPCG is being planned.
A unique aspect of developing something intended for widespread use is the need to identify and offer only the essential core. In this way, what is offered can be considered, ideally, as generic, and therefore as having a broad scope for relevance and utility. The NPCG were developed, reviewed, and refined to this end, to ensure that individual and specific NP programs would not feel constrained or limited in their offerings or vision for NP education. At the same time, however, it was felt that the NPCG would not serve any intended audience if advanced practice as applied to the NP role was not identified and addressed by specific philosophy, content, and objectives. The following discussion is directed toward this intricate balance between generic and specific content. The intention is to provide NP faculties without narrowly limiting their vision of the NP role.
Philosophy and Assumptions About the NP Role
The philosophical view expressed within the NPCG was based upon criteria from the two major national nursing organizations, the ANA (1980) and the National League for Nursing (NLN) ( 1989). Essentially these organizations agree that advanced practice is based on a generalist, i.e., baccalaureate, preparation in nursing and that curricula for advanced practice must provide a theoretical and research base specific to the practice area. This base for NP practice is predicated on the construct of primary health care, with all of its attendant concepts of direct contact, comprehensive care, case management, prevention, health, and wellness.
In addition, the AHEC grounded the curricular guidelines in the assumption that NP curricula must provide for specific NP role development by including integrated clinical learning opportunities under the direction of those faculty who are involved in advanced practice of primary health care. This clinical component is necessary, not only for learning technical skills, but also as essential for acquisition of clinical decision-making skills and clinical judgment that must undergird every action of the NP.
In the NPCG, a model is provided to depict all advanced practice as situated in the theory and research necessary to establish a basis for such a practice (Figure 1). The NP role within advanced practice is depicted as being derived from an educational curriculum that builds upon the generalist background. The NP curricula, then, provides the theory and research essential to advanced practice in primary health care through classroom and clinical learning opportunities.
Conceptual Framework: Content and Learning Experiences for NP Education
Choosing specific content for the NPCG was the ultimate challenge. What concepts, theories, and experiences would be considered basic for NP education? Was there one particular framework for presenting this content?
Before developing the new guidelines, the AHEC reviewed examples of current NP curricula from universities and colleges in Texas, Michigan, Indiana, Virginia, Washington, Mississippi, Oregon and California. Both certificate and master's level programs were reviewed. Within all of these curricula there was inclusion of content addressing the following:
* advanced technical skills associated with performing and interpreting findings from the history and physical examination;
* information specific to disease management;
* content on nursing theory, diagnosis, health promotion, disease prevention, lifestyle counseling, and family systems theory;
* dynamics and care during chronic phases of illness;
* emphasis on a holistic approach to care; and
* clinical judgment and clinical decision-making (AHEC, personal communication, 1988-1989).
The AHEC considered the curricular review to be necessary and helpful in consolidating ideas about NP educational content, but it was an insufficient basis for recommending particular content. The AHEC then turned to a review of available research on the process of NP practice. In particular, three relevant pieces of research were carefully reviewed. These included the research of Brykczynski (1985), Hanson (1986), and Monninger (1987). These investigators identified both the extant practice of NPs and the competencies required to function effectively in the NP role.
The competencies for NP practice identified in Hanson's (1986) and Monninger's (1987) work were also reflected in Brykczynski's ( 1985) study of NP practice. Brykczynski, however, identified six broad domains of practice which the AHEC thought could be successfully adapted to a curricular framework. Thus, this was the organizing framework adopted for the NPCG.
There were some additional reasons for choosing Brykczynski's (1985) work as the NPCG framework. Importantly, like the studies of Hanson (1986) and Monninger (1987), it is grounded in the ernie experience of the NP. Also, it represents a departure from a "technical" view of NP practice by capturing the lived experiences of both the NP and the client (Diekelmann, 1988). As an experimentally based framework, it lends itself to the ever-changing process of clinical practice as shaped by the provider, clients, and societal trends.
This particular framework had additional advantages from the AHECs perspective. It offered a way to organize a large amount of curricular content, yet retain sight of the primary health care basis of practice. Theories and concepts necessary for NP practice could be identified readily within specific domains. Furthermore, the framework did not promote or advocate any specific nursing theoretical framework. This latter advantage allows for individual NP faculties to overlay any nursing framework.
In consultation with Brykczynski, the AHEC collapsed the original six domains to five. The five domains identified and adapted from Brykczynski 's work include:
1. Management of client health/illness status in ambulatory care settings;
2. Monitoring and ensuring the quality of health care practices;
3. Organizational and work role competencies;
4. Helping role; and
5. Teaching-coaching function.
To approach these domains from a curricular perspective, each domain was considered for its specific content, objectives, and competencies. An example of this is provided in Figure 2, which is a description of Domain 3: Organizational and Work Role Competencies. Each domain also is accompanied by a statement of the rationale for the selected content.
Characteristics of the NP Graduate
The intended educational product of the NPCG is characterized throughout the document. The NP graduate is one who has approached advanced practice education with a generalist background in nursing and who would possess the following competencies:
* the ability to observe, conceptualize, diagnose, and analyze complex clinical or nonclinical problems related to health;
* knowledge of a wide range of theory relevant to understanding health problems; and
* the ability to select and justify application of theory deemed to be most useful in understanding those problems, and in determining a wide range of treatment options (ANA, 1980, p. 23).
Obviously, the educational process for the NP must include a strong clinical component that allows adequate time for recognizing and developing skills of clinical assessment and judgment that is reflective of an independent and autonomous practitioner. This does not negate the NFs collaborative role with other health care professionals, but it does target the uniqueness of NP learning to assure a clinical posture that provides complete and competent management based on one's assessment and judgment. These skills are further nested within activities of health education and health promotion for all clients.
Characteristics of NP Faculty
The value and availability of clinically confident NP faculty cannot be underestimated. These faculty attend to the quality and frequency of clinical opportunities for the NP student. They also construct a sequential process enabling each individual learner to acquire competency in clinical decision-making at an advanced level of practice.
Successful socialization of the NP learner is dependent upon such faculty to serve as role models and as resources for professional networking. These faculty also engage in and encourage the students' involvement in primary health care research. Such mentoring assists the students not only in learning clinical management, but also in asking relevant questions about their practice. In this way, new NP graduates can contribute toward building a broader and stronger knowledge base for NP practice and education.
Brower, Tappen, and Weber (1988) make a particularly strong appeal for NP curricula to retain NP faculty. From their survey of 136 NPs, they concluded that while "graduate programs offer broader frames of reference and emphasis on research," those educated in such settings may suffer serious insecurity about their clinical competence. Without faculty who are prepared as NPs, graduate programs may be in danger of further diluting the practitioner portion of the program.
Issues Facing NP Education
In addition to developing curricular guidelines for NP education, the AHEC determined that some discussion of issues facing the NP role generally and NP education specifically was necessary. Therefore the NPCG contain a section of discussion of general issues currently facing graduate education for NPs. These issues include, but are not limited to, availability of and access to accredited NP programs; costs of additional education, particularly for nurses involved in family support; and availability of flexible, creative NP programs designed to accommodate the commuting and working student. While these concerns are not directly related to curriculum development, they do have an impact on present and future NP education.
As educators and curricula developers, NP faculty will be called on to address these problems and creatively strategize to keep their programs viable and relevant. At the same time, faculty and new graduates will have to continue to maintain a critical mass of NPs in the marketplace and to retain a competitive position in health care delivery. Brower et al. (1988) remind us that the conditions of a physician shortage, under which the NP role first developed, no longer exist, and while research may reflect physician acceptance of the NP role, that role is by no means economically secure in today's milieu of a competitive health care system. Therefore, NPs, and particularly NP educators, must clearly define the NP role and its contribution to today's health care needs. This definition is crucial to NP education and NP curricula, and must be clearly reflected in the classroom and clinical settings.
The need to maintain a critical mass of NPs in the marketplace further mandates that both certificate and graduate NP programs align themselves in a posture of support and strength toward the goal of promoting a practice of nursing that is clinically and theoretically sound. Brower et al. (1988) note that both certificate and graduate programs have limitations and strengths. The atmosphere in health care presently requires that attention to differences be minimized while common goals and strengths are maximized.
Domain 3: Organizational and Role Competencies*
An advanced practice role for NPs, as proposed in the NPCG, is seen as one that entails application of a broad range of theories to selected (primary health care) phenomena within the discipline of nursing. The role also carries with it an increased amount of complex technology and knowledge in the practice arena. Collectively, these changes in NP function and role have prompted a review of the curricula that serve to prepare the NP for extant and future practice.
The emphasis on specific characteristics of NP faculty has also been addressed in the NPCG. Faculty who practice as NPs are considered to be critical elements to the curriculum's development and administration. Such faculty offer an understanding of the NP and provide the setting for RN transition to the NP role.
NP education for the present and the future must be developed and guided by the rich and rapid NP role evolution. Drawing from this background, the NPCG are intended to be grounded in a review of existing curricula as well as research about NP practice. They are to be considered as generic and, therefore, flexible for site-specific NP curriculum development. The NPCG have been planned to be a timely adjunct to the present state of NP education and to guide future NP curriculum development.
In conclusion, the AHEC determined that any curricular framework for NP programs of the 1990s and the 21st century should capture the historical perspective of the NP role. The NP role must be clearly identified as one competent in providing myriad primary health care services with comprehensive, competent clinical skills and the ability to work effectively within complex, interdisciplinary, health care delivery systems. In addition, the NPCG have included content that will prepare the NP graduate for participation in the function of health care citizenship - that of improving practice through legislation and health care policy setting at local, regional, and national levels. And, most importantly, the AHEC sought a framework that retains the focus of nursing care that perceives client management from the perspective of wellness, illness prevention, and maintenance of optimal health.
- American Nurses Association. (1975). Guidelines for short-term continuing education programs preparing adult and family nurse practitioners. Kansas City, MO: Author.
- American Nurses Association. (1980). Nursing: A social policy statement. Kansas City, MO: Author.
- American Nurses Association. (1990). Professional certification: 1990 certification catalog. Kansas City, MO: Author.
- Billingsley, M.C. (1986). The process study. Nurse Practitioner, 11(1), 52, 68.
- Brower, H.T., Tappen, R.M., & Weber, M.T. (1988). Missing links in nurse practitioner education. Nursing & Health Care, 9(1), 33-36.
- Brykczynski, KA. (1985). Exploring the clinical practice of nurse practitioners. Dissertation Abstracts International, 46, 3780B. (University Microfilms No. 86-00, 592)
- Brykczynski, K.A. (1989). An interpretive study describing the clinical judgment of nurse practitioners. Scholarly Inquiry for Nursing Practice: An International Journal, 3, 75-104.
- Diekelmann, N.L. (1988). Curriculum revolution: A theoretical and philosophical mandate for change. In Curriculum revolution: Mandate for change (pp. 137-157). New York: National League for Nursing.
- Feldman, M. J., Ventura, M.R., & Crosby, F. (1987). Studies of nurse practitioner effectiveness. Nursing Research, 36, 303308.
- Geolot, D.H. (1987). NP education: Observation from a national perspective. Nursing Outlook, 35, 132-135.
- Hanson, OH. (1986). Desired competencies for nurse practitioners: A delphi study of master's level curriculum priorities. Dissertation Abstracts International, 47, 47 12 A. (University Microfilms No. 87-06, 868)
- Johnson, R.E., & Freeborn, D.K. (1986). Comparing HMO physicians' attitudes towards NPs and PAs. Nurse Practitioner, 11(1), 39, 53.
- Kulal, S., & Clever, L. (1974). Acceptance of the nurse practitioner. American Journal of Nursing, 74, 451-456.
- Mauksch, I. (1978). The nurse practitioner movement - Where does it go from here? American Journal of Public Health, 68, 1074-1075.
- McGrath, S. (1990). The cost-effectiveness of nurse practitioners. Nurse Practitioner, 15(7), 40-42.
- Monninger, M.E. (1987). A description of professional competencies of family nurse practitioners and congruence of goals of practice. Dissertation Abstracts International, 47, 2375B. (University Microfilms No. 86-18, 549)
- National League for Nursing ( 1989). Criteria for the evaluation of baccalaureate and higher degree programs. (6th Ed.) (NLN Publication No. 15-1251). New York: Author.
- National Task Force on FNP Curriculum and Evaluation, D.E. Jelinek & B.E. Umland (Eds.). (1980). Guidelines for family nurse practitioner curriculum planning. Albuquerque, NM: University of New Mexico Duplication Facility.
- Office of Technology Assessment, U.S. Congress. (1986, December). Nurse practitioners, physician assistants, and certified nurse midwives: A policy analysis (p. 19). Washington, DC: U.S. Government Printing Office.
- Pearson, L. (1990). How each state stands on legislative issues affecting advanced nursing practice. Nurse Practitioner. 15(1), 11-18.
- Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S., Gent, M., Kergin, D.J., Hackett, B.C., & Olynich, A. (1974). The Burlington randomized trial of the nurse practitioner. New England Journal of Medicine, 290, 251-256.
- Zimmer, P., Brykczynski, K, Martin, A.C., Newberry, Y.G., Price, M. J., and Warren, B. (1990). Advanced nursing practice: Nurse practitioner curriculum guidelines. (Final Report: NONPF Education Committee). Washington, DC: National Organization of Nurse Practitioner Faculties.
Domain 3: Organizational and Role Competencies*