The need to change the way that nurses are educated is well documented in recent publications (Bevis & Watson, 1989; NLN, 1988). The practice of nursing has, for some time, been considered too separate from the education of nurses (Maukasch, 1981). This separation of education and practice has led to some common misunderstandings between these two groups. Bevis and Watson recommend that practice and education work together to address a variety °f issues and trends of interest to nursing. The recommendations included: the congruence between nursing's philosophy, theory, research, practice, and education; the increasing complexity of the needs of the health care system; the need for greater access for nursing education; and needs of students who are demographically different than they were 20 years ago. A curriculum revolution was initiated in North America in the 1980s to respond to these issues (NLN).
One of the tenets for change is a practice-driven curriculum. This change demands a shift in approach from the historical tendency of nursing educators, practitioners, and researchers to work in isolation from each other. This notion was supported by a literature search that revealed a surprising lack of articles showing educators in collaboration with practitioners for curriculum development. Valuing each other's work and establishing collégial relationships is essential for the future of nursing as a discipline (NLN, 1988). Therefore, it is relevant and essential to involve practitioners in curriculum development.
A Collaborative Partnership
A collaborative partnership consisting of five schools of nursing in four regions of British Columbia was created in 1989: the University of Victoria (U Vic), Okanagan University College (OUC), the University College of the Cariboo (UCC), Camosun College (CC), and Malaspina College (MC). A collaborative curriculum team and a steering committee were formed to oversee the work of the curriculum's development and implementation. The partners envisioned an emancipatory curriculum where student nurses would be empowered and their work valued by themselves and by others.
The first task the partners undertook was to write a curriculum philosophy which was informed by feminist, humanistic, existential, phenomenological, and socially critical orientations. These influences came to be reflected in the philosophy's view of persons, health and healing, health care, nursing, and curriculum (Ministry of Advanced Education [MAE], 1991, p. 3). The new nursing curriculum emphasized learning outcomes, critical and conceptual thinking, the quality of student and faculty interactions, individualization of the learning process, and self-responsibility for lifelong learning. A unique feature of this curriculum was the emphasis on clinical experience as the foundation of nursing theory, and the recognition that nurses' work requires thoughtful, reflective action as defined by the concept of praxis (Hills, Lindsey, Chisamore, Bassett-Smith, Abbot, & FournierChalmers, 1994).
The collaborative partners used a variety of strategies, both site-specific and cooperative, to include practicing nurses in the development of the curriculum. An example of a site-specific strategy was a course planning workshop followed by course writing teams composed of faculty and practicing nurses. An example of a collaborative multi-site strategy was a Delphi survey of practicing nurses in the four regions that the partner institutions service (two institutions are located in the same region). The purpose of this article is to describe the Delphi survey, the results of the survey, and curriculum implications.
Building Consensus for Curriculum
A Delphi survey was developed from a brainstorming session. At a meeting held at one partner site, practicing nurses invited from regional institutions and agencies were informed about the new curriculum and asked to respond to the following question: "Given the changes that you have seen in your practice, what do you anticipate the nurse of the future will need to do, know, and be to provide high quality nursing care?" A list of responses was generated which later formed the 30 items for the Delphi survey.
The Delphi survey method was chosen as the most appropriate methodology because the research required the input of experts for decision making (Dalkey & Helmer, 1963); the practicing nurses were considered to be the experts. The Delphi technique, first developed in the 1950s, has been widely used in nursing (Beddome, Clarke, & Whyte, 1993; Farrell & Scherer, 1983; Henry, Moody, & Penergast, 1988). The Delphi technique, a survey method of research, uses a group process to generate discussion among a number of individuals and enables a judgment to be made on a specified topic so that decisions can be taken which can claim to represent a given group's wants and needs. The technique consists of a series of questionnaires. Responses to each round of questionnaires are analyzed, summarized, and returned to the participants. Based on knowledge of the group's viewpoint, the participants can reformulate their responses. The process stops when consensus has been reached, which was the intent of this study (Delbecq, Van de ven, & Gustafeon, 1975).
One criterion of this study was to involve practitioners in each of the five site regions. The expense of bringing them together for face-to-face decision making was prohibitive, thus, the Delphi approach provided an excellent method. Thomas (1974) describes the Delphi approach as quiet, thoughtful conversation, in which everyone gets a chance to listen. The effects of domination by leaders or very local participants are eliminated. The guaranteed anonymity, another criterion of this study, promotes an honest expression of views and protects the participants from penalty or mockery (Goodman, 1987). To address a criticism that participants may make hasty, ill-considered judgments, participants were provided ample space to comment on each of their choices, as requested in the instructions.
In the first phase, participants were asked, via colorcoded questionnaire, to rank the 30 items in order of importance for what the future nurse would need to do, know and be, to comment on each item, and to add items to the list. The 30-item list was condensed from a list generated at an earlier brainstorming session. Responses to the questionnaires were analyzed and summarized by the research team and returned to the entire sample, even those who did not respond in phase I. In the second phase, participants were asked to rank order again the 30 items, revised to reflect responses in phase I, and to make comments on the items.
Data from questionnaires from both phases were entered into a computer line-file and analyzed using SPSS. Measures of central tendency for each item were calculated and sums were used to determine the group's rank ordering of the items. The item-specific comments were content analyzed into categories of issues. Phase II data, when compared with that of phase I, indicated that general consensus had been reached (see Table 1 for the top 10 items of phase I and phase II according to rank order).
The sample plan was designed to represent nurses from the five site regions, as well as a diversity of clinical areas, nursing roles, and practice settings. The sample consisted of staff nurses, including recent graduates and upper and middle management. There was a ratio of one upper management to two middle management to three staff from acute care hospitals, extended and intermediate care facilities, and community programs. There were 243 nurses in the sample: 111 were from Victoria, 55 from Okanagan and Shuswap valleys, 27 from Nanaimo, and 50 from Cariboo-Chilcotin. There were differences in respondents' educational level (see Table 2) and number of years of practice (see Table 3). The response rates for phase I and II were 46.5% and 40% respectively; Victoria participants responded at a rate of 56.7% and 45.9%, Okanagan at 30.9% and 34.5%, Cariboo at 46% and 33%, and Nanaimo at 37% and 40.7%. The survey was conducted during the summer when nurses are on vacation, so this might have had an impact on the response rate. Subjects were from 30 different work areas.
The findings are discussed in two sections: ranking the items and themes.
Summary of the Items
The following 10 items scored consistently high in both phases of the survey, with minimal change in items between the two phases. The first item was the highest ranked item in both phases, with the largest raw score. The top 10 items are discussed in order of the final ranked priority.
Comparison of Rank Order of Top 10 Items for Phase 1 and Phase 2
1. Have increased accountability and responsibilfor their practice. There was strong agreement participants regarding the importance of this item. said nurses are responsible to themselves, clients, professionals, and society. Many identified that operationalization of accountability and respondepended on having authority and autonomy for practice, a broad BSN education, knowledge of of practice, and decision making based on principles.
2. Make decisions. Participants stated that decision has always been a major part of nurses' work. nurses have not always been encouraged to act their decisions, they should be. Decision-making skills learned in the classroom and from experience. To decision-making skills, participants suggested need a broad knowledge base and an internship provide sufficient clinical experience. In addition, need to be creative and assertive.
3. Liaise with other disciplines and agencies. stated that nurses cannot be "all things to all people," and that they will liaise with other disciplines and agencies to provide holistic client care. To achieve this, nurses must be valued members of the health care team. liaising role was seen as closely linked with a coordinating role. Nurses will need to be informed about community partnership programs and the resources for continuous client care.
4. Think critically. The importance of critical thinking was illustrated in the comments of one nurse who said, "This ensures the ability to cope with changes and a complex environment, and the ability to develop needed skills." Another respondent pointed out that "critical was encouraged, but not fully valued."
5. Teach the public. Responses to this item included informing the public about "what nurses do," as well as teaching clients health promotion. Participants stated that nurses need to know how to present workshops. Teaching was viewed as "enabling" to do for self rather than "doing for."
6. Use community resources. While participants agreed that knowledge of community resources is necessary for discharge planning, client advocacy, and assisting elderly people to stay in their homes, they were divided as to whose responsibility it will be to know about community resources. Some said "we must all have knowledge," while others said "we can't know everything." Some linked this function with item 6, "liaising with other disciplines." Participants suggested that nurses need to know about community resources, particularly community nurses. Nurses also should know the differences and similarities between hospital and community nursing.
Education Preparation of Respondents
7. Do more assessments. Participants suggested that assessments will not be more in number, but will be more comprehensive and sophisticated. Comments included "Nurses should be the entry point to the health care system."
8. Act as a change agent. Participants stated that being a change agent was an essential part of primary health care, of nurses' work with clients in hospitals and community, and of the shift in focus from illness to wellness. Change theory and skills as a change agent were seen as a means to influence colleagues, politicians, and the public to set healthy public policy. Nurses themselves also need to be skilled at accepting and adjusting to change.
9. Leadership. One participant stated that "leadership is not done, it's lived." Participants stated that nurses need to learn leadership and management skills in order to plan and implement nursing care, work with interdisciplinary teams, provide leadership for nurses, promote change, and undertake political action on health issues.
10. Perform nursing functions autonomously. Participants identified the necessity of clarifying nursing and non-nursing functions and the importance of accountability for successful autonomous practice. Also mentioned was the need for balance between functions that will be done independently and functions that will require collaboration with other health care team members.
Comments from the remaining 20 items were analyzed and sorted into three themes. These themes are education, professionalism and image, and leadership and political voice. Some theme comments relate to those expressed in the item section; other comments are different.
Education. Participants said nursing education needs to include an opportunity for specialization as well as a holistic generalist approach. Numerous skills were identified as important: clinical, interpersonal, assertiveness, critical thinking, technical and computer, political, research, writing, and marketing. Areas of competence identified as important included: detailed anatomy and physiology, gerontology, cross-cultural, community, legalethical issues, a global view of health including care of the environment, primary health care, health promotion, planning and implementing programs for groups, theorybased practice, management, and budgeting. Also identified was the need for more nurses prepared at the masters and doctoral levels.
Professionalism and image. In addition to attributes already listed under "education" that pertain to "professionalism" and nursing image, other factors were noted as necessary for professionalism. Participants identified the following: self-motivation, need for lifelong learning, need for self-esteem as a person, and professional and humane caring.
Participants also identified attitudes and behaviors that are consistent with professionalism: the need for nurses to support nurses and nursing, the willingness to preceptor students, a commitment to the public, making nursing a career not a job, taking responsibility for personal health, and being a lifestyle role model.
Leadership and political voice. Participants made additional recommendations in relation to leadership: be an articulate public speaker, advocate and lobby for nursing equity within the health care system, and develop improved strategies for nurse retention and better recruitment of people into nursing.
The comments of the participants addressed current issues which needed to be addressed in our present curriculum and provide direction for the future. The survey findings were forwarded to the collaborative steering and curriculum committees. The responses reflect current shifts in societal health care needs, the Canadian health care system, and nursing practice, which have been incorporated into the collaborative nursing curriculum.
Consistent with the results of the Delphi survey, together with health care trends (CPHA, 1986; Epp, 1986; RNABC, 1989; Royal Commission, 1991), the curriculum reflects a shift in focus of nursing from the traditional medical model in acute care settings to the broader base of health promotion in a variety of settings. The shift from hospital care to community care (Royal Commission) is reflected in a better balance of health promotion, illness prevention, and illness care content. In addition to faculty-supervised practica within academic semesters, concerns about skills and competencies are addressed by increased consolidated clinical experiences in wide and diverse settings. These experiences provide ideal opportunities for the integration of knowledge and skills required within a practice discipline such as nursing. Finally, the curriculum offers students the opportunity to pursue individual interests in a variety of nursing specialty areas along with their preparation for beginninglevel Registered Nurse positions in hospital and community health care settings (Ministry of Advanced Education, 1991).
Similarly, the curriculum reflects recommendations from respondents related to the issues of the second theme, professionalism and image, in the goals, themes, and teaching methods. The curriculum's goals for the professional character and image of nursing have several features. Its graduates are to be independent, selfdirected, self-motivated, and a lifelong learner with a questioning mind and a familiarity with inquiry approaches to learning. They are to be scholars who are self-reflective, self-evaluative, accountable, and make clinical judgments based on different ways of knowing, including critical thinking and intuition. They are to create and influence the future of nursing practice at a political, social, and professional level by responding to and anticipating the changing needs of society (MAE, 1991). The metaconcept and theme of the curriculum is caring based on the work of Watson (1988), Benner (1984), and Leininger (1980). Caring is understood as the attitude and activity of nursing and is considered in every nursing course (Hills, Lindsey, Chisamore, Bassett-Smith, Abbot, & Fournier-Chalmers, 1994). Its teaching methods are to be innovative; they are to emphasize learning outcomes, critical and conceptual thinking, the quality of student and faculty interactions, individualization of the learning process, and self-responsibility for lifelong learning. The curriculum assists students to become cognizant of nurses' professional role.
Recommendations made by respondents in relation to the third theme, leadership and political voice, are addressed with the choice of concepts within the curriculum. The focus on health promotion acknowledges the need for a socio-ecological orientation with a multidisciplinary context. Concepts such as empowerment, responsibility, perception, choice, advocacy, hardiness, self-help, and vulnerability are explored throughout the program (Hills & Lindsey, 1994). Learners will examine challenges to health and people's experiences of the challenges and mobilization of resources to deal with the challenges. Students will learn to work as partners with clients and with other health care providers. Through their understanding of and participation in the changing health care system, graduates will be active participants in creating health for all (Hills, Lindsey, Chisamore, Bassett-Smith, Abbot, & Fournier-Chalmers, 1994).
The Delphi survey and other strategies were used successfully to engage practice colleagues with nursing faculty in curriculum development. The outcome was a curriculum that represented the cumulative efforts of over 200 educators, nurse administrators, and practicing nurses.
The curriculum was enhanced by this successful collaboration between education and practice, and the belief that the one group possessed what the other lacked. Both groups became enthusiastic at the prospects of working together to create a curriculum. Whenever there is a major change in the preparation of nurses, students and new graduates are not always helped or welcomed. We hope that our ongoing work with nurses in practice will alleviate the negative history of changes in nursing education. Collaborative efforts continue between education and practice as we launch the new curriculum. Faculty have been speaking to agency staff about how to operationalize new paradigm principles such as empowerment of clients and staff Agency staff continue to offer suggestions about curriculum content and practicum experiences. The benefits to both education and practice nurses of this collaborative process partnership continue to be experienced as the curriculum is implemented.
In summary, the collaboration between nursing education and practice in the development of a baccalaureate curriculum has been an informative and worthwhile endeavor.
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Comparison of Rank Order of Top 10 Items for Phase 1 and Phase 2
Education Preparation of Respondents