The transformation of the health care system during the past decade has caused many universities to reconsider their nursing curricula. The advent of managed care, the demand for health care reform, the rapid advancement of technology, and the paradigm shift from disease treatment to health promotion and illness prevention all have contributed to the evolution of the role of the professional nurse. Nine trends shaping health care and professional practice were identified in Recreating Health Professional Practice for a New Century: The Fourth Report of the Pew Health Professions Commission (Pew Health Professions Commission, 1998). These were cost control, oversupply of resources, an aging population, information technology, advances in the treatment of disease, improving quality, the changing role of the health care consumer, disparities in the population, and the broadening definition of health. These trends require that nurses possess a skill set required for successful practice in the emerging health care system (Table 1).
Despite this transformation, many nursing curricula, including the one at the authors' university, have continued to prepare nursing graduates who are equipped to meet the demands of yesterday's health care system. In 1998, the faculty of the University of Southern Mississippi (USM) College of Nursing began the process of revising the nursing curriculum. Despite periodic updates and minor revisions, the curriculum had been in place for nearly 15 years. The faculty believed the time had come to take a critical look at the nursing profession, the education system, and the ways in which nurses are prepared to function in the modern health care environment.
The faculty's first decision was to select the American Association of Colleges of Nursing (AACN) with its accrediting branch, the Commission on Collegiate Nursing Education (CCNE), as the accrediting agency. When the CCNE accreditation standards (1998) were examined, along with the AACN publications, The Essentials of Baccalaureate Education for Professional Nursing Practice (1998a) and The Essentials of Master's Education for Advanced Practice Nursing (1998b), it became clear that the faculty needed to build a new curriculum, rather than try to "patch up" or reconfigure the old one.
The purpose of an organizing framework is to provide for faculty and students a meaningful picture of the knowledge that is important to nursing and how that knowledge is defined, categorized, sequenced, and linked with other knowledge. A curriculum organizing framework lends vision to a discipline's scope of knowledge. Acting as a blueprint, the framework serves to structure knowledge in a meaningful way for both faculty and students, as well as administrators, evaluators, and others (Boland, 1998). The organizing framework that was in place at USM was outmoded. Based on the nursing process, the horizontal strands and vertical organizers of the model made little sense to the faculty and were ambiguous and confusing to students and others. Furthermore, Gold, Haas, and King (2000) pointed out the following:
The use of the nursing process as a conceptual framework should be avoided because it is a method of thinking. It does not reflect the knowledge that iß essential to nursing thinking and practice, nor to the actual use of the nursing process itself (p. 98).
Clearly, the faculty needed a new framework that reflected the AACN curriculum recommendations, as well as their own values and beliefs about nursing education.
As shown in the Figure, the organizing framework was designed as a sphere with multiple layers. The model depicts the progression of knowledge acquisition from the core liberal arts and foundation courses through the nursing curriculum to the program outcomes expressed as roles and attributes of graduates. The innermost circle represents the liberal arts education and scientific foundation for human caring that is the cornerstone on which disciplinary knowledge is built.
The framework has at its center a navigational compass (Figure). The compass is symbolically significant in that it provides direction, while guiding travelers toward their destination. As nurse educators, the faculty uses the organizing framework as a compass as they navigate through the range and scope of nursing knowledge. The model shows the points of the compass extending out into the four quadrants of nursing knowledge, symbolizing the continuing influence of core knowledge on subsequently acquired disciplinary knowledge.
The middle circle represents nursing knowledge and is divided into four quadrants:
* Core nursing knowledge.
* Core nursing competencies.
* Nursing role development.
* Professional nursing values.
The broken lines demarcating the quadrants indicate movement and the varying emphases placed on the different quadrants at different points in the program. For example, early in the program, greater emphasis is given to the acquisition of core nursing knowledge and competencies, while later in the program, the emphasis shifts to role development and professional values. However, at graduation, there should be a balance among the quadrants connoting the faculty's belief in the equal importance of all aspects of professional nursing education.
The outer circle represents the outcomes of the curriculum expressed as roles and attributes to be possessed by graduates. Billings and Halstead (1998) cleverly compared a curriculum framework to a road map, outcomes to a trip's destination, and competencies to mileage markers along the way. Outcomes and competencies provide ways to measure accountability in nursing, not just for student behaviors but also for patient and nurse behaviors in health care settings. The USM faculty is indebted to the faculty of Indiana University, who initially developed nine of the core characteristics and who generously provided permission to use them in this model (Halstead, Rains, Boland, & May, 1996). In addition to these, the USM faculty added three characteristicsresearcher, leader, and advocate (Table 2). Deliberately unbounded, this circle symbolizes the potential for continued professional growth in these areas and signifies the faculty's commitment to the principle of lifelong learning.
The emphasis on outcomes in health care is not new. In the 1880s, Florence Nightingale used a systematic method of recording and analyzing health care conditions and patient outcomes during the Crimean War (Fralic, 1999; Johnson, Maas, & Moorhead, 2000). However, through the years, structure and process began taking precedence over outcomes in education and health care settings when faculty and health care administrators discovered the complexity of trying to measure educational and patient outcomes.
Skill Set for Successful Nursing Practice In the 21st Century
Figure. University of Southern Mississippi College of Nursing organizing framework.
However, in the past decade, evidencebased practice has become a priority as cost effectiveness and managed care have become major influences in the health care industry. Evidence-based practice, where nurses help patients attain desired outcomes as cost effectively as possible, has forced nurse educators to reevaluate their curricula to graduate nurses who can fulfill the expectations of the current, ever-changing health care arena. Possessing expertise in measuring outcome effectiveness, providing excellent leadership and management, continuously discarding old information and implementing new ideas, and working cohesively with an interdisciplinary health care team have become critical skills for successful practice in today's modern, technology-intensive health care environment.
Competencies and Definitions of Advocate Role
Evidence-based practice for nurse clinicians and educational outcomes for student nurses are so interconnected the two cannot be separated. In fact, priority shifts and changes in the health care system have a substantial influence on the design of nursing curricula. If nurse educators are to produce valuable and competent nurse clinicians who can prevail over rapid changes, a focus on educational outcomes should be the pivotal point when redesigning a curriculum. Outcomes, or attributes, that nurse educators want their graduating nursing students to possess should be delineated before the actual revision of the curriculum occurs. The outcomes then serve as the driving force for the revision and are reflected throughout the new curriculum.
After the USM faculty's organizing framework and outcomes were established, the competencies that provide the measurement through the different levels in the nursing program were defined. The competencies were written for three levels of measurement: pre-nursing (i.e., at the start of the nursing program), junior (i.e., at the end of the first year of nursing), and senior (i.e., at graduation) (Table 2). The competencies need to be written to reflect adequately the desired level of student learning (Billings & Halstead, 1998). An outcome-driven curriculum, unlike behavioral objectives, promotes a dynamic process in which responsibility for learning is a joint endeavor by students and faculty.
Nurse educators are faced with numerous challenges. Successful clinical practice rests with nurses' ability to solve problems and think critically. Nursing graduates must be prepared to recognize complex clinical phenomena as relationships that have potential solutions (Brock & Butts, 1998). It is imperative that nursing curricula prepare graduates who are able to meet the demands and expectations of an evolving health care system, which is driven by cost control, consumer satisfaction, and overall quality. To meet this expectation, an outcome-driven curriculum is fundamental.
Education is a dynamic process that responds to internal and external environmental influences. Nursing curricula must ensure graduates are prepared to be successful in the current practice environment, as well as in future health care environments. This curriculum model provides a flexible framework that accommodates change and recognizes continued growth within the profession and its members. Reflecting the synergism of its parts, the goal of the model and the curriculum it represents is to prepare nurses who are able to promote optimal health and maximize human potential through caring.
- American Association of Colleges of Nursing. (1998a). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author,
- American Association of Colleges of Nursing. (1998b). The essentials of master's education for advanced practice nursing. Washington, DC: Author.
- Billings, D.M., & Halstead, J.A. (1998). Teaching in nursing: A guide for faculty. Philadelphia: Saunders.
- Boland, D.L. (1998). Developing curriculum frameworks, outcomes, and competencies. In D.M. Billings & J.A. Halstead (Eds.), Teaching in nursing: A guide for faculty (pp. 135-150). Philadelphia: Saunders.
- Brock, A., & Butts, J.B. (1998). On target: A model to teach baccalaureate nursing students to apply critical thinking. Nursing Forum, 33(3), 5-10.
- Commission on Collegiate Nursing Education. (1998). Standards for accreditation of baccalaureate and graduate nursing education programs. Washington, DC: Author.
- Fralic, M.F. (1999). Nursing leadership for the new millennium: Essential knowledge & skills. Nursing and Health Care Perspectives, 20, 260-265.
- Gold, C., Haas, S., &. King, Ï. (2000). Conceptual frameworks: Putting the nursing focus into core curricula. Nurse Educator, 25(2), 95-98.
- Halstead, J.A,, Rains, J. W., Boland, D.L., & May, P.D. (1996). Reconceptualizing baccalaureate nursing education: Outcomes and competencies for practice in the 21st century. Journal of Nursing Education, 35, 413-416.
- Johnson, M., Maas, M., & Moorhead, S. (Eds.). (2000). Iowa outcomes project: Nursing outcomes classification (NOC) (2nd ed.). St. Louis: Mosby.
- Pew Health Professione Commission. (1998). Recreating health professional practice for a new century. The fourth report of the Pew Health Professions Commission. San Francisco: Author.
Skill Set for Successful Nursing Practice In the 21st Century
Competencies and Definitions of Advocate Role