The etymological definition of the word curriculum is from the Latin, curriculum, meaning a "contest in running ... a chariot race" (Simpson, 1960, p. 163). The aim of a race is to finish, although arguably some would say, to win. A revolution in sports psychology has led parents to ask their children, not, "Did you win?" but rather, "How are you progressing?" Similarly, dramatic changes in our health care system and the resultant revolution in nursing education have brought us to an uncharted course with no end in sight. As we struggle to prepare nurses for both today and the 21st century, we need to accept that there is no blueprint for "winning" this curricula revolution; it is an evolving process with no finish line. The challenge for nurse educators is to envision beyond the traditional, illness-centered approach (Sullivan, 1995; Tanner, 1990) to a more holistic, healthoriented model. The purpose of this article is to provide a case example of the process of change from an integrated, acute-care focus to a community-based, health promotion framework.
The origin of the curriculum revolution in nursing became evident in 1986 when the National League of Nursing (NLN) and the Society for Research in Nursing Education acknowledged the impact of new technology, changing demographics, and dramatic shifts in the health care system as a mandate for change in nursing education (Henderson, 1990; National League for Nursing, 1988, 1989; Tanner, 1990). Tanner (1990) identified the major themes of this initial phase of the revolution: social responsibility; caring as a central value; theoretical pluralism; and the primacy of the teacher-student relationship.
In 1991, the Pew Health Professions Commission Report challenged educators of the health professions to dramatically reshape their curricula to meet the broad health needs of the population both from a community and preventive perspective (Bellack, 1995; Shugars, CNeil, & Bader, 1991). Among the essential competencies identified by this Commission were: the ability to provide cost-effective, primary health care in a culturally diverse society; the promotion of healthy lifestyles, the integration of information management skills; and the inclusion of patient/families in decision-making (Barger, 1994; Shugars et al., 1991).
By 1993, this commission joined voices with the NLN and the American Association of Colleges of Nursing (AACN) to urge nurse educators to prepare their students to practice in community-based settings that emphasize health promotion and rehabilitative primary health care with interdisciplinary collaboration (AACN, 1993; BeUack, 1995; NLN, 1993). To achieve this aim, the NLN began a national campaign to support community-based nursing education and practice, entitled the Vision Campaign for Nursing Education Reform (News from NLN, 1994, September; NLN Visions ? Project, 1996).
The American Nurses Association (ANA) and the National Student Nurses Association (NSNA) also recognized during the early 1990s that significant reform in nursing education was essential to meet the changing needs of the population in an evolving health care system (ANA, 1993; Barger, 1994; NSNA,1993). The ANA identified the most significant trend as the changing focus to preventive, primary care in the community as opposed to the highly technical, complex tertiary level of care in the hospital setting (ANA, 1993; Barger, 1994). Also, the student nurses organization recommended that the focus on illness and cure move to wellness and care (NSNA, 1993).
Since the advent of the revolution in nursing education 12 years ago, many schools have responded to the challenge, both in the United States, and other countries as well (Bellack, 1995; Owen-Mills, 1996). Although the need for change toward a community-based approach in nursing care and education is clearly supported in the literature (Barger, 1994; Bellack, 1995; Clarke & Cody, 1994; Canavan, 1996; Hall-Long, 1995; Lindeman, 1996; Manuel & Sorenson, 1995; Noble, Redmond, Williams, & Langley, 1996; Oesterle & O'Callaghan, 1996; Sullivan, 1995; Tanner, 1990; Wilkinson, 1996; Zotti, Brown, & Stotts, 1996), the process of this change is less often described.
More commonly, specific objectives related to curricula change are discussed, such as the restructuring of clinical experiences toward a community-based approach (Ehrhart & Furlong, 1996; Faller, Dowell, & Jackson, 1995; Faller, Graham-Wilson, & Howlett, 1993; Palmer, 1995; Reinhard et al., 1996; Yoder, Cohen, & Gorenberg, 1998); inclusion of gerontology from a health promotion perspective in the curriculum (Alford & Futrell, 1992, 1998; Barry & Burggraf, 1996; Collins, Butler, Gueldner, & Palmer, 1997; FutreD, 1996); critical thinking curriculum initiatives (Cascio, Campbell, Sandor, Rains, & Clark, 1995; Kataoka-Yahiro & Saylor, 1994); and identification of specific concepts included in nursing curricula (Johnson, 1995; Valiga & Bruderle, 1994). One exception is the description of the process of reformation experienced at the University of Hawaii School of Nursing (Oneha, Sloat, Shoultz, & Tse, 1998). These authors outlined their experience of developing a multidisciplinary partnership with other professional schools and the community they served.
IMPETUS FOR CHANGE
Since the inception of the nursing major at the University of Massachusetts Lowell (UML) (formerly Lowell State College) in 1968, the curriculum has undergone only one major revision. The previous revision incorporated a stress, crisis, and adaptation theory framework. Beginning in the sophomore year, the curriculum used an integrated approach, with core content related to health problems interspersed throughout. A close link between the didactic content and the concurrent clinical experience often got lost in the integration process.
In the early 1990s, the nursing faculty were well aware of the changes in the health care system and the proposed education revolution suggested by the major nursing and educational organizations. In the fall of 1993, the department chair initiated the discussion of curriculum change among the faculty at several departmental and curriculum committee meetings. At this time the faculty also had the charge of reviewing the congruence between the program goals of the undergraduate, master's, and newly created PhD program in nursing. The NLN had just accredited the existing program that same year, which allowed time for planned change prior to the next scheduled accreditation in the year 2001.
The faculty recognized that the profile of the UML nursing student had evolved to include an increasing proportion of RN, associate degree students, second degree students, and other midlife career change students who sought mqre flexibility in their program of study. At this juncture, the need for a new curriculum was agreed upon by the majority of the faculty, but this was not a unanimous sentiment. Most faculty members recognized that the ANA Standards of Clinical Practice (1991) should remain the foundation of professional practice for the students, but how to impart those standards and in what clinical settings became the subject of debate. Because past graduates had been very successful and enjoyed excellent reputations in the community, in some faculty's eyes, the curriculum was not broken, so why fix it?
THE PROCESS OF CHANGE
Although Tanner (1995) has suggested that traditional curriculum change processes, averaging 18-24 months, are far too slow for the revisions necessary in the current unstable health care environment, our transformation evolved over a dynamic three-year process. Within this relatively long time frame, some faculty expressed that the process was moving too hastily over this three-year period. Change can be painful and rarely was there unanimous consensus on major issues along the way. Methods that facilitated curriculum generation included: designing and refining a curriculum template, revisiting values, releasing "sacred cows," and bunding consensus.
Laying the Groundwork
The first major effort in laying the groundwork for the new curriculum consisted of a reconfiguration of the structure of the curriculum committee. First, an ad hoc subcommittee, the Curriculum Revision Committee was formed. The charge of this subcommittee was to examine both the issues within the current program and those outside the university. The committee sponsored a faculty workshop to discuss key concepts, such as health promotion, and to examine the mission and objectives of the department.
Survey Results of 25 Nursing Undergraduate Programs
Data Gathering and Analysis
To examine national trends, evaluate the current curriculum, and project a future curriculum, the Revision Committee collected data by a variety of methods including surveys of alumnae, faculty, students, and other universities. The committee also conducted a critical review of the nursing education literature and analyzed national trends of nursing school curricula.
The Nursing School Survey. The committee developed a four-question survey to send, along with a request for their catalog, to 59 schools of nursing across the country. These consisted of 12 nursing baccalaureate programs in the same state (MA) to assess for local trends and 47 schools considered the highest rated nursing schools in the Gourman Report (1993). There were 25 schools that responded (42%), including 17 from the top-rated programs and 9 from nursing programs in MA. In addition to the information obtained from the survey, committee members selectively reviewed the course catalogs for the program structure, courses offered, and philosophical underpinnings. These were presented as a stimulus for discussion among the committee members.
The results of the survey suggested that major curriculum revisions had already occurred in the majority (88%) of these schools during the past ten years (Table 1). These changes included switching from an integrated to a nonintegrated model (back to clinical and course work in closer alignment); changing the start of entry to nursing courses; creating a community-based primary care orientation; and revising the philosophical or theoretical underpinning of the program.
Alumnae Survey. The year prior to this formal curriculum review, 103 graduates of the classes of 1987 through 1991 responded to a survey (51% response rate) on program satisfaction, employment, salary, and professional development. Overall, the alumnae reported a high degree of satisfaction with the program, particularly with nursing courses versus non-nursing requirements. The committee reviewed the suggestions of 74 alumni who recommended improvements in the program. Areas identified most often as needing improvement were clinical placements, faculty-supervisory role, and specific content in nursing courses. Alumnae also recommended changes related to clinical lab/assessment skill preparation, and specific course prerequisites.
Student Curriculum Survey. In addition to student input from representatives on the Curriculum Revision Committee, the committee developed a survey for seniors during their final semester. This questionnaire included a 4-point rating scale (no, Little, moderate, to great value) for each course required in the program. The survey also asked the students to rate their perceived competency in 20 identified areas of nursing practice. An open-ended question concluded the survey with a comments/suggestions section.
The questionnaire was completed by 37 seniors (51% response rate). Of the 28 required courses, most were rated favorably by the students. However, one third of the students identified 8 of the prerequisites to nursing as problem areas (rated as little or no value). These included 2 psychology courses, general statistics (not an applied course), and the 2 general chemistry courses. Students also wrote in numerous suggestions for existing nursing course changes, despite rating them favorably. The majority suggested the addition of new required courses (versus including content via the integrated approach): pharmacology (85%), nutrition (74%), and research (51%).
The seniors rated themselves as average to above average in most of the identified competencies. The strongest areas were communication, advocacy, the nursing process, holistic approach, writing, and organizational skills. The weaker competencies identified included understanding research, legislative processes, and cross cultural competence.
Faculty Curriculum Survey. Based on the student survey, the committee surveyed the faculty in a similar format to evaluate each course and perceived student competencies. Unlike the student questionnaire, this survey also included a question on which curriculum model the faculty member preferred (integrated, nonintegrated, other, or not sure).
There were 19 faculty members who responded (83%), 12 of whom primarily taught at the undergraduate level. Interestingly, for evaluation of the prerequisite, non-nursing courses and the nursing courses, many of the faculty did not believe they had sufficient knowledge to give the course an evaluative rating. For 14 of the non-nursing prerequisite courses, 1 to 4 faculty members marked "unsure" for the rating. This number of uncertain values increased to nearly a third of the faculty respondents in the nursing courses, indicating lack of familiarity across the curriculum when outside one's specialty or primary assigned teaching level within the department.
Although the ratings were not generally as low as the students, there was a tendency among faculty to rate the same courses less favorably. The faculty agreed with students, albeit at a lower agreement rate, regarding the recommendation to require specific courses in nutrition (63% in favor) and pharmacology (69%). A slightly higher percentage (58% versus 51%) of faculty responded that a research course should be a requirement. The faculty also concurred with the students regarding the perceived level of competency among the students, rating competencies in the nursing process, communication, and organizational skills as particularly strong.
Faculty-Modified Delphi Survey. To facilitate the tedious process involved in critical examination of specific outcome objectives and development of new ones, the faculty agreed to participate in a modified Delphi survey. This method helps to achieve consensus of opinion within a group to examine present and past standards in light of predicted future trends (Everett, 1993). The Delphi method typically includes a seven step process with three major rounds of consensus-seeking (Everett, 1993; Lindeman, 1975) and has been used in nursing research as a consensus building process (Misener et al., 1997; Nugent, Barger, & Bridges, 1993; Proctor & Hunt, 1994). In the first round, the previously identified "terminal" objectives were listed with a choice for each: maintain, modify, or delete. This three-choice method was a modification of the traditional rank-ordering system used in the Delphi technique. Similar to the traditional method however, the UML survey incorporated a qualitative section which asked for comments related to any suggested modifications or deletions.
Round one of the process resulted in modifications of 9 out of 10 previously identified outcome objectives. This round of responses generated 2 new outcome objectives. The second Delphi survey was distributed with a similar evaluation format for the 9 revised, 1 untouched, and 2 new objectives. Once again, changes were recommended for each of the new objectives derived from round one, with a consensus to delete one of the newly generated objectives from round one.
Round three, in contrast to the previous two rounds that were written, anonymous responses, consisted of open discussion of the revised objectives, based on round two data at a faculty workshop. This method of achieving consensus, while differing from the traditional Delphi technique, was adopted to meet the committee deadline within the academic year and to allow a forum for open discussion at this critical point of the process. Faculty reviewed each objective derived from round two, suggested minor modifications, and adopted the resulting nine program outcome objectives by a majority vote. Table 2 identifies the original objectives and the end product after three rounds of consensus building.
Six major outcomes of the groundwork phase from year one resulted in decisions that facilitated progress on to the next phase. These consisted of: moving toward a health promotion-focus; incorporating a communitybased model; shifting toward a family-oriented lifespan approach; changing to an upper level division program; removing the integrated approach; and involving the entire faculty in the process. Members of the curriculum committee consisted of graduate and undergraduate faculty, representing all specialty areas in nursing. Two chairs, representing both the undergraduate and graduate faculty now steered the effort of engaging the faculty as working members in the deliberative processes ahead.
Designing a Template
Because of the multitude of changes proposed, it became difficult for the committee to envision an all new curriculum. Open-ended discussions precluded coming to closure on many of the issues relating to a new curriculum. The momentum of the committee began to stall. The araimittee chairs responded by developing a template or "picture" of a new curriculum to which the committee members could react. Data sources for this template included the department mission statement and objectives, minutes from previous faculty meetings and workshops, credit allocation information, a literature review on nursing curricula, and review of survey data collected. The design of a template was an experiment in trying to move the revision process forward. The template itself was a one page document portraying the four semesters of a new upper division curriculum. The chairs assigned rudimentary courses with proposed, sequencing, and credit allotments.
Comparison of Original Outcome Program Objectives and Revised Delphi End Product
Revising the Template
Revisions of the template became an ongoing process in an attempt to modify and shape the new curriculum to best meet student and program needs. Progress in curriculum development resumed, albeit deliberate and slow. Issues of debate centered around the progression of course content, credit allotment, sequencing, naming of courses, and student clinical experiences in a communitybased curriculum. To facilitate progress, the chairs reworked the template after each meeting and distributed the latest template prior to each subsequent meeting.
Revisiting Values and Sacrificing "Sacred Cows"
Benner's work on the progression of novice to expert (1984) enlightened the discussions at this time in addition to the adopted health promotion definition of Kulbok, Baldwin, Cox, and Duffy (1997). According to these scholars, health promotion is defined as "organized actions or efforts that enhance, support, or promote the well-being or health of individuals, families, groups, communities, or societies'' (p. 17). The faculty concurred that the curriculum should incorporate a focus on the priorities identified in Healthy People 2000 (U.S. Dept. of Health and Human Services, 1991). As noted by others involved in curriculum reform, the faculty realized that educating nurses with an emphasis on health-promotion involves much more than the mere addition of new health content into the curriculum (Hills & Lindsey, 1994).
As educators, the faculty believed that they needed to reinvent their own roles as facilitators of learning (Bailey, 1992). As mentors to nurses of the future, the challenge was to prepare leaders and nurturers in nursing roles that the faculty had not perhaps experienced themselves. Research has suggested that the nursing role of the future is evolving into a managerial, leadership clinician as opposed to a technically competent one. In one study of nurse executives, the most commonly cited nursing skill for the nurse of the future was that of delegation and supervision (47%) as opposed to increased clinical skills (35%) (Manuel & Sorenson, 1995).
Although the faculty had reached consensus on a community-based approach with close alignment between clinical and didactic components, the issue of how to provide this experiential learning was always in the fore of the deliberations. It was difficult for faculty to transfer clinical experiences that had always been inpatient to clinical learning experiences primarily located outside the hospital setting. Sacred cows that were difficult to relinquish during this phase included letting go of traditional acute inpatient pediatric, psychiatric, and maternity clinical experiences. Faculty created a listing of essential skills, based on the revised program goals and objectives and devised a plan to incorporate them in the new curriculum.
The New Health Promotion Curriculum
After two years of deliberation and negotiation, a majority vote by faculty established an agreed upon template of a new curriculum. The organizing framework consisted of a lifespan approach to health promotion with clinical practica located predominantly in the community.
Creation of New Courses
The committee now invited all faculty to work on ad hoc subcommittees to develop and further refine individual course descriptions and objectives. These subcommittees included three to four members considered experts in the content area. A subcommittee also reviewed the RN to BS program to ensure its compatibility with the curriculum revision philosophy. A member of the curriculum committee chaired each of these working groups and acted as liaison to the larger committee. Each subcommittee was responsible for a didactic and its related concurrent clinical course or a stand alone theory course.
As the subcommittees established course names, descriptions, and objectives, the larger curriculum committee reviewed these periodically to review the fit within the larger organizational scheme of the new curriculum. Occasionally, as the committee deliberated on one course, the structure of another course would need alterations as well to maintain continuity. The committee assisted in course development through four main processes: identification of essential concepts necessary for each course; refinement of objectives to demonstrate a logical progression; review for duplication and omissions; and revision of final products to achieve consistency and balance throughout the health promotion curriculum. In light of the recommendations from the AACN (1998, January) and NLN (1993), the core competencies of critical thinking, communication, and therapeutic nursing interventions also required clearly evident, measurable objectives.
Issues of Refinement and Closure
Eventually, the committee agreed upon an essential draft of each course and presented it to the faculty for consideration and approval. With a majority approval by vote, the committee had successfully completed its goalthe approval of a revolutionary new curriculum model. The final curriculum template consisted of a 2/2 model, with nursing courses starting in the junior year (Table 3). New required courses included nutrition, pathopharmacology, community health policy, and health care research.
The next hurdle was the approval by the state Board of Registration in Nursing. This was successfully achieved upon first submission. Faculty efforts then centered on further clarification of course content and continued exploration of community-based health organizations for clinical experiences. In 1996, the first group of nursing students enrolled in the program as freshman in this new curriculum. Faculty teaching the junior year nursing courses for the first time in the fall of 1998 were building on the health promotion foundation created by the entire faculty in the new curriculum. This challenge has contributed to a feeling of empowerment and unity among the faculty. The implementation and evaluation of this phase will be forthcoming in future nursing education forums. The faculty will evaluate the new curriculum based on its established objectives through student, faculty, and clinical agency community surveys. Curriculum evaluation will also include close scrutiny on NCLEX exam rates, job placement, and alumnae and employer satisfaction.
IMPUCATIONS for nursing AND NURSING EDUCATION
Barger (1994) suggests that no one strategy will meet the needs of all schools as they seek to incorporate the NLN "vision" for education reform (NLN, 1993). The UML experience is but one example of a school that sought to create a new vision, given the regulatory rules of its own department, those of the university, local state nursing board, and its unique mission within the community. The faculty submit that the current plan is not a panacea formula to last the next 20 years. However, it is hoped that it will provide a flexible framework to usher the undergraduate nursing program into the next century.
Although different nursing program curricula will evolve to meet specific community needs and university objectives, it appears that an essential change in nursing education must, at the very least, involve a switch from the skills/content-based approach to learning to an outcome/competency-based learning environment (Halstead, Rains, Boland, & May, 1996). In the context of today's knowledge explosion, the content that was once held so dear is outdated in some areas before the students have even graduated. As nursing educators enter the "crossroads of the next millennium" (Hall-Long, 1995, p. 139), they need to prepare nurses to enter the managed-care marketplace of today and for the, as yet unknown, health care system of the future. This evolving nursing role may well include preparation to work autonomously outside institutional settings (Hadley, 1996).
In the context of this current "revolution" in education, universities must remember that the idea of the profession as a community-based, health-promoting vocation traces back to the historical public health nursing tradition in this country (Reinhard et al., 1996; Stanhope & Lancaster, 1996) and indeed to the roots of the profession. In reference to the study of disease versus health promotion, Nightingale (1859) spoke eloquently of the "confusion of ideas, which is hard to attempt to disentangle" (p. 74). She forewarned her colleagues to not lose sight of the value of nursing:
Pathology teaches us the harm that disease has done. But it teaches us nothing more. We know nothing of the principle of health . . . except from observation and experience. And nothing but observation and experience will teach us the ways to maintain or bring back the state of health (p. 74, 75).
The process described in this article reveals that curriculum change often evokes a similar "confusion of ideas." As the AACN noted in its draft on the essentials of nursing education, "New and expanded roles and opportunities for professional nurses will continue to be created" (1998, January, p. 2). As nurse educators and leaders redefine the roles of the profession and the objectives of nursing education, they need to continue to dialogue, share the process, and carefully evaluate these endeavors.
The authors wish to acknowledge the contributions of the students, faculty, and alumnae of the nursing program at the University of Massachusetts Lowell. In particular, Dr. May Futrell and Dr. Nina Coppens contributed to this effort with their ongoing support during the curriculum revision process and their careful review of this manuscript.
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Survey Results of 25 Nursing Undergraduate Programs
Comparison of Original Outcome Program Objectives and Revised Delphi End Product
The New Health Promotion Curriculum