Foreign Literature

Curriculum Revolution:
Laura A. Stokowski, RN, MS In 1988, the National League for Nursing (NLN) attempted to shake nursing schools loose from the hold of the traditional, content-laden, lecture-and-test approach to nursing education. In Curriculum Revolution: Mandate for Change: nursing leaders called for an overhaul of nursing education that would change the way nursing was taught and learned. The changes in curriculum did not succeed. During the ensuing 25 years, under the auspices of "reform," nurse educators essentially re-arranged and updated the curriculum without changing the substance of the curriculum itself or the educational paradigm.[6] In 2003, the NLN once again advocated a transformation of nursing education, via the creation of innovative pedagogies that will be effective in helping students learn to practice in rapidly-changing environments.[6] Graduating nurses would be leaders in health promotion and disease prevention, function in complex and unpredictable environments, demonstrate critical reasoning and flexibility, and execute a variety of roles throughout their nursing careers. The old and tired clinical placement model would give way to an approach that has relevance for the increasingly community-based, multidisciplinary patient care delivery systems of the future. We now come to 2009. An initiative known as the Future of Nursing (FON), a joint project of the Institute of Medicine and the Robert Wood Johnson Foundation, began its critical review of the nursing profession by holding 3 national forums, one of which focused on nursing education. This forum was led by Michael Bleich, RN, PhD, Dean of the Oregon Health & Science University School of Nursing. Participants in this forum considered needed innovations in what to teach (ideal future nursing curricula), how to teach (methodologies and strategies), and where to teach (venues and locations for nursing education). The recommendations that came out of this forum were driven by 4 realities (1) more nurses are working outside of hospitals as care shifts formally and informally into communities; (2) evidence that could inform practice is growing rapidly, but is not well-integrated into either education or practice; (3) the need for nurses to effectively work in and lead teams is increasing; and (4)

numbers alone will not fill the widening gap between the supply of nurses and the growing need for their services -- additional research and new knowledge will be required. The emphasis in nursing education is sometimes perceived to be on preparing students for their nursing boards, but as Michael Bleich pointed out, "The licensure exam is a minimum standard -- it tests only for minimum safe competency. But the public wants more than that. They want optimal competency, especially in the specialized areas. We have to move beyond the notion of comparing nursing programs for their abilities to assure graduates are minimally competent, and the public is challenging us, and saying how are you going to do this?" It is a common misconception that competencies are task-based proficiencies. The student demonstrates the ability to take a blood pressure, or give a subcutaneous injection, and the instructor makes a checkmark on a skills list. Competencies are actually higher level skills that represent the ability to demonstrate mastery over care management and that provide a foundation for decision-making skills under a variety of clinical situations across all care settings. Examples of competencies are:

Clinical judgment; Critical reasoning; Evidence-based practice; Relationship-centered care; Interprofessional collaboration and teamwork; Leadership; Assisting individuals and families in self-care practices for promotion of health and

management of chronic illness;

Teaching, delegation, and supervision of caregivers; Genetics and genomics; Cultural sensitivity; Practice across the lifespan; End-of-life care; and Professionalism. [211]

Nurse Education in Practice: Implementing a clinical competency assessment model that promotes critical reection and ensures nursing graduates readiness for professional practice.
Competence is a complex concept that is difcult to dene and measure. The assessment ofnursing students clinical competence has confronted universities with problems of validity, reliability,subjectivity and bias for many years. This presents particular problems in nursing as patient outcomesmay be compromised by incompetent practice. Too often assessments of nursing students competence brief assessments of psychomotor skills, vague global assessment of generic skills/attributes or assessments undertaken in simulated laboratory settings rather than the real world of practice. Methods: The Structured Observation and Assessment of Practice (SOAP), is a full day holistic practice driven clinical competence assessment approach that motivates nursing students learning, promotescritical reection and conrms graduates readiness for professional practice. This model was introducedin 2004 and since then 1031 students have been assessed. Quantitative and qualitative data has beencollected via an anonymous online evaluation. The results of the SOAP approach supports the premise that quality clinical assessment requires nursing students exposure to complex challenges undertaken in authentic clinical contexts, observed by registered nurses who are trained as assessors and have a strong educational and clinical background. Competence remains a complex concept that is difcult to dene and even more difcult to measure (FitzGerald et al., 2001; Watson et al., 2002). The assessment of nursing students clinicalcompetence has confronted educationalists with problems of validity and reliability over an extended period of time (Girot, 1993,2000). Assessors often give learners the benet of the doubt andfail to fail incompetent learners, unless there is very clear evidenceof unsafe practice (Lankshear, 1990; Watson et al., 2002). Thispresents particular problems for the nursing profession as patientoutcomes may be compromised by poor practice. While universities aim to prepare nurses to work in complex, dynamic andunpredictable clinical environments, too often clinical assessmentsare focused on psychomotor skills and fail to take into account themultidimensional nature of competence and the range of attributesrequired for professional

practice. In order to address theseeducational and professional concerns an innovative clinicalassessment model has been implemented into the Bachelor of Nursing program at the authors university. This paper outlines thedesign, implementation and evaluation of the cornerstone of thismodel, the Structured Observation and Assessment of Practice(SOAP). It is a comprehensive and practice-driven clinical assessment that motivates student learning, promotes critical reection One of the challenges underpinning clinical assessment isdening the term competence. Watson et al. (2002, p. 422)suggests that competence is a nebulous concept dened indifferent ways by different people. Its relationship to other concepts such as capability, performance and expertise is also unclear(Eraut, 1994). Gonzi (1994) describes three ways of understanding competence: (a) task related skills; (b) pertaining to generic attributes essential to effective performance; and (c) the bringingtogether of a range of general attributes such as knowledge, skills and attitudes appropriate for professional practice. This integratedand holistic approach aligns with the denition of competence provided by the Australian Nursing and Midwifery Council. The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance ina profession/occupational area. It is this denition of competence that has been adopted for the SOAP model. Conversely, an assessor unknown to the student may need to base their decision regarding the competence of a student, on a very short period of observation that may not be representative of the students overall performance (Watson et al., 2002). Indeed, the students performance during this brief period of observation may be adversely inuenced by intrinsic factors (for example, anxiety) or external factors (such as patient acuity on a particular day), and these factors need to be taken into account during the assessment. [212]

Global Standards in Nursing and Midwifery Education

One of the reasons for the nursing curricular reform is to incorporate global standards in the Philippines nursing curriculum. Implementation of the standards will facilitate progress towards the highest level of education attainable in a country or region, assure equitable and appropriate placement of nurses in health-care roles and, potentially, simplify recruitment practices throughout the world (WHO, 2009). The goal of the global standards is to establish educational criteria and assure outcomes that: a. are based on evidence and competency b. promote the progressive nature of education and lifelong learning; and c. ensure the employment of practitioners who are competent and who, by providing quality care, promote positive health outcomes in the populations they serve. The global standards in the nursing curriculum are divided into four areas. These are Curriculum Design, Core Curriculum, Curriculum partnership, and Assessment of Students. Each has its own criteria as stated below: 1. Curriculum Design Take into account workforce planning flows Meet national and international education criteria Delivers the knowledge and skills required to meet the needs of their respective populations. Demonstrate balance between the theory and practice components of the curriculum. Use of recognized approaches to teaching and learning Provide classroom and clinical learning based on established competencies Enable the development of clinical reasoning, problem solving and critical thinking Conduct regular evaluations of curricula and clinical learning Offer opportunities for multidisciplinary content and learning experiences 2. Core Curriculum provide core content that will enable their graduates to meet the established competencies provide core content in nursing theory provide core through the primary health-care approach

 provide supervised clinical learning experiences 3. Curriculum Partnership develop partnerships with other healthcare disciplines use inter-professional teamwork approaches have access to, and arrangements for, the clinical learning sites 4. Assessment of Students assess student learning using reliable evaluation methodologies use a variety of methods to assess the subject matter have student retention systems in place The new curriculum adopted the global standards in nursing curriculum. The global standards was adopted to enhance global competitiveness. The Core Competencies also have the same goal to improve global competitiveness. Under the criteria of the core competencies, the researchers will evaluate if the new nursing curriculum will or will not be able to meet the goals of international standards. [213]

Caring as the central focus in nursing curriculum development. Bauer JA.

Nursing literature and conferences are advocating a return to the humanistic values and caring approach to people that has been a hallmark of nursing. A theory base for caring in nursing is emerging. Over the past 10 years several research studies in nursing have focused on the concept of caring. Most studies have dealt with defining and understanding the concept of caring and identifying attributes of caring from the perspective of the patient/client and from that of the nurse. New work on caring is looking at teaching of the concept in schools of nursing (Bauer, 1988), the economics of caring (Buerhaus, 1986), the relationship between caring and nurse burnout (Gustafson, 1984), issues of ethics and caring (Fry, 1988 & 1989), to name just a few. The concept of caring is being legitimized as an area appropriate for nurses to study. As nursing educators know, building a program on a strong philosophical base with faculty committed to implementation of the program philosophy is crucial for success of program outcome. Using a caring framework for teaching nursing exposes nursing students to more than an empirical basis for practice. A holistic approach to really understanding people as human beings of value, worth, and having needs becomes the focus of content. To effectively teach caring, faculty must role model the attributes of caring to nursing students. This involves accepting and treating students as having value, worth,

and the potential for growth. Faculty must also feel good about themselves and their abilities as teachers. Faculty need to feel confident and comfortable in their role as educators, master their subject matter, and be willing to get involved with students. Faculty development programs, recruitment of faculty espousing a caring philosophy, and mentoring new faculty into their modeling role are important considerations for the effective teaching of caring. Promoting a caring framework for nursing and faculty modeling of caring behaviors and attitudes could affect student recruitment. In our highly technologic society, great emphasis is being placed on person-to-person relationships. Reaffirming the caring nature of nursing to the public and actively promoting these behaviors may make the nursing profession a more attractive and appealing career choice. [214]

A New Curriculum for a for a NEW ERA of Nursing Education

By Giddens, Jean; Brady, Debra; Brown, Pauline; Wright, Mary; Smith, Debra; Harris, Judith Academic journal article from Nursing Education Perspectives, Vol. 29, No. 4 Publication: Nursing Education Perspectives Date: July-August 2008 Volume/issue: Vol. 29, No. 4 The need for curriculum reform, a common theme in the nursing and health sciences literature for a number of years, is becoming urgent. This article describes an innovative undergraduate nursing curriculum. Central to the curriculum revision were the adoption of a conceptual approach, the institution of clinical experiences driven by conceptually based learning, and a focus on experiences across population groups and practice settings. An innovative, web-based community was developed as a platform for the curriculum. Over the past decade, there has been growing evidence of the need for change in health professions education. Multiple issues concerning educational preparation and entry into practice are cited by the Institute of Medicine (I), giving rise to a call for major educational reform that is echoed in the n u r sing literature. The Essentials of Baccalaureate Education for Professional Nursing Practice, which details core standards for baccalaureate education, has been influential in curriculum development since 1998, but its authors have asked if it is even possible to "prepare beginning-level professional nurses for the future in a four-year time flame" (2, p. 19). * Tanner described the expectations set forth in The Essentials as a "blueprint for the 21-year curriculum" (3, p. 383), but she was unable to identify any of the core knowledge and competencies outlined in

The Essentials that could be eliminated. More recently, the National League for Nursing has called for Dramatic reform, with a challenge to re think the emphasis on content and outdated teaching practices. The NLN suggests that a complete paradigm shift in Nursing Education is indeed. . * With these issues in mind, our institution developed and implemented a new undergraduate curriculum to foster a conceptual understanding of nursing practice. The new curriculum has four unique features that are consistent with suggestions found in the nursing education literature: * Three undergraduate options are merged under one program of study. * A conceptual approach has been adopted. * New approaches to clinical education have been instituted. * An innovative, web-based teaching platform has been created. Merging Undergraduate Tracks Like many other nursing programs, our program has several options available to obtain a baccalaureate degree in nursing: a four-year track for traditional students; a track for students with a previous bachelor's degree in a field other than nursing (second-degree track); and an online RN-BSN track. In reviewing the curricular needs of these three options, faculty identified a need to minimize duplication of content between courses in the various tracks. Duplication of content creates an obvious drain on already stretched faculty resources, and there was consensus that all students need the same nursing curricular preparation for degree and licensure. While consolidation of tracks has been identified as a short-term strategy to expand the capacity of current faculty (5), there remained the challenge of how to provide the same curriculum to the traditional and second-degree tracks while still providing a mechanism to obtain the degree in the shortest time possible. It was determined that the primary curricular differences between traditional and second-degree tracks would be the necessary prerequisite courses. [215]

The Recognition of Prior Learning (RPL)

Students of nursing bring abilities and attitudes to their nursing courses. Within the course the knowledge and skills of nursing are presented. Together the educators and students attempt to integrate knowledge with caring, abilities with skills, skills with knowledge and so on. Not all students of nursing in formal courses are beginners. Many possess valuable skills and knowledge that are relevant to nursing. The Recognition of Prior Learning (RPL) of skills, experience and qualifications can be expedited by the use of Competencies. If a student or nurse believes they already possess the integrated attributes required in some aspect of nursing, they could be assessed against the Competency and gain RPL. Savings in costs of education and time for the learner can be achieved in this way. However to date, this aspect of the use of Competencies in nursing has not been widely used. Gonczi & Hager (1992) Define competency as the ability to perform the activities within an occupation or function to the standard expected in employment. One of the central themes of the use of Competencies in education is the change of focus from what a student is taught and the knowledge they learn, to outcomes, or demonstration of what the learner can actually do. Many nurses have difficulty in understanding the competency movement because nursing has traditionally prepared its students in settings and in a manner that closely resembles this description. Hospital-based schools of nursing presented theory and skills for learning that were highly relevant and functional to the standard expected in the hospital ward. Since the move of nursing education to tertiary settings, the workplace nature of much of the learning and application of that learning has altered. However, nursing courses for Enrolled and Registered nurses remain based upon the knowledge, skills and attitudes nurses are expected to demonstrate in employment in a wide variety of contexts and settings. More emphasis is placed on ensuring every participant gains and is able to apply the required competencies in the course of their occupation or profession. Competency-based Education and Training have been introduced to many occupational and trade vocational preparation programs as well as to some professional programs and courses such as nursing. Henderson (2009) contended that RLE as part of the nursing curriculum is an imperative component which intends the learned nursing skills and nursing procedures be put into action by student-nurses as they are exposed to different clinical areas, units, and wards. With the target of

developing the nursing competencies among the student-nurses, provision should be made for adequate physical facilities, supplies, and equipment for effective nursing care and learning experiences of students in base and affiliate hospitals. This practicum side of nursing is where the theoretical knowledge is applied by the student nurses in clinical settings. It is also the actual performance of nursing procedures that nursing skills are improved towards the acquisition of skills intended to quality patient care (American Journal of Nurses, 2008). Here, they learn to nurse by actual nursing hamessing the best practices by the staff and clinical instructors which should be passed to the students making the hospital a functional nursing laboratory (Sotejo & Jackson, 1992). Schute and Sherwill-Navarro (2008) asserted that evidence-based practice require nursing educators to rethink their curricula and consider how these skills can be integrated throughout their programs. They also require nursing educators to examine their own abilities to find and utilize best nursing practice that is relevant to their practice, teaching pursuits, and students practical needs. Collaboration among those involved in education and the actual hospital workplace is vital to producing future nurses who are equipped with knowledge and are able to apply this in their daily practice. [LYKA]

Nursing at its Best: Competent and Caring

Marilyn K. Rhodes, CNM, Gordon (2005) described the historical, stereotypical (iconic) view of the nurse as that of a physicians handmaiden, dependent on the physician for direction. She explained that the nursing profession has been negligent in sharing with the public the importance of nurses critical thinking, problem-solving, and research skills. Nurses have failed to help the public understand that nurses actions involve more than nurturing; they also include assessing, surveying for risks, identifying client goals, planning independent actions, and prioritizing care. Gordon (2006) has stated that in order to gain and maintain the respect of the public and other healthcare professionals, nurses must emphasize and communicate the knowledge and skills required for professional nursing. It is also imperative that those responsible for reimbursement of nursing care understand that nurses save lives, prevent complications, prevent suffering, and save money (para. 5). OMara (1999) has argued that in order to assure reimbursement and access to needed resources nurses need to articulate the cognitive abilities nurses need in order to provide competent care. Benner, Sutphen, Leonard, and Day (2010), too, have written that nurses must learn to emphasize the tangible

benefits of nurses, beyond that of caring. In the remainder of this literature review we will look at motivations for choosing nursing as a career and review the literature identifying the need for both competence and caring skills in nursing.
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Setting of Goals in nursing

Ramona Browder Lazenby, EdD, RN, FNP-BC, CNE According to Locke and Latham (2002), personal goals are vital for direction and maintenance of behaviors that help to achieve future rewards. Effective goal setting can be a source of motivation as an individual pursues a career. The social cognitive career theory (SCCT) has postulated that self-efficacy beliefs and outcome expectations are key motivators for career selection. Individuals who are confident of goals, who believe in their ability to reach their goals, and who believe that goal attainment will lead to a successful career are able to complete the tasks required to achieve their goals (Lent, Brown, & Hackett, 1994). In a systematic review of literature related to career choices of gifted and talented students, Miller and Cummings (2009) identified one career motivator as the perception of a fit between a career and ones personal self-concept. Miller and Cummings found career choices to be based on the belief that an individual possesses the necessary traits to be successful. They also found that career choices were influenced by family members, specifically mothers. These gifted students preferred careers that were prestigious and required higher levels of education. Hoke (2006) observed that to recruit talented students, the nursing profession must educate the public regarding the high level of critical thinking required for nurses and the potential for nurses to impact global problems. Emmons (1999) approached career choices from a strivings perspective in which goals are assessed based on what the individual is striving to achieve. The list of possible goals is then assessed for the impact of specific motives on the persons choice of goals. Other motivating factors for career choices may be based on spiritual beliefs, feelings of being called into a specific area, and materialistic desires (Dik, Sargent, & Steger, 2009).
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 Competence and Caring Arlene H. Morris, EdD, MSN, RN, CNE The U.S. Institute of Medicine (IOM) (2003) mandated increased attention to factors that promote quality and safety of patient care. Since this mandate was issued, outcomes of patient care have become increasingly important. In response, Cronenwett et al. (2007) have proposed that statements of the knowledge, skills, and attitudes (KSAs) for each competency should be developed during prelicensure nursing education (p. 122). Competencies identified by the IOM and addressed by the Quality and Safety Education for Nurses (QSEN) now include patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007; IOM, 2003). The American Association of Colleges of Nursing (1998, 2008) and the National League for Nursing (2007) have identified caring as a foundational value for nursing. Shultz (2009) has described attempts in nursing education to guide progression from a personal identification as a caring person to a professional identity of caring. Benner (2000), Benner, Tanner, and Chelsa (2009), and Benner and Wrubel (1989) have proposed that caring is a requisite for the development of critical thinking. Stowe (2006) investigated educational strategies in nursing education that were designed to promote understanding of caring as an abstract concept and concluded that nursing educations efforts to impact a more consciously caring individual for our society is invaluable (pp. 127-128). The above insights support Purnells (2009) conclusion that caring includes themes of struggle, discovery, hope, humility, and spirituality (p. 115). Falk-Rafael (1996) proposed that caring in nursing has evolved from an ordered (or required) caring (associated with characteristics such as nurturing), to an assimilated caring (as nursing developed into an autonomous profession), and then further evolved to an empowered caring (as individual nurses realized nursing interactions support caring connections) within an interprofessional healthcare delivery system that has an ever-changing power base. Falk-Rafael suggested that empowered caring is informed by both knowledge and experience.
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Nursing characteristics: Central to nursing

Ramona Browder Lazenby, EdD, RN, FNP-BC, CNE Over two-thirds expressed caring as an essential Nursing characteristic. Many described caring as essential, the most important trait, central to nursing, or critical to the role. Some provided perspectives from those receiving care: non-caring [nurses] will give a negative persona, a caring nurse can cause patients not to be scared, and the absence of care will affect patients psychologically, emotionally and physically. Others indicated that caring separated nursing from other professions and is essential for providing holistic care, writing for example, must care to give patients the best possible care. Other comments included without caringnot a nurse and even if no one else cares, nurses do. Students identified caring as a motivation to be competent so as to promote positive Outcomes for patients. They noted that caring increases competence, ensuring nurses will properly assess patients and perform skills. Other responses included: Without caring, you will not do your best. This will impact the dedication of nurses to provide holistic care. One willing to teach, listen while giving competent care. Caring also was considered necessary to prevent complications by checking the patient as often as needed and performing skills that may be unpleasant. Regarding the theme Connection and Trust, students described the importance of caring in establishing the nurse-patient relationship from both the nurse and patient perspectives. Caring is essential in developing the trust in the nurse-patient relationship, a patient [is] more likely to interact and communicate with a caring nurse, allows clients to understand their self-worth, and a nurse connects and develops relationships by caring. Comments indicated that caring leads to trust which results in a positive impact for the patient. Responses included comments, such as patients will most likely trust and relax/reduce anxiety and once a positive relationship [has developed, the nurse] can focus on health promotion of the client. Additionally, students addressed potential problems if caring were absent, noting that the nurse might be competent but

not show any compassion or care to your patient. This builds a wall .then your patient will not open up to you.This could interrupt a nurses assessment of a patient. Students also indicated Giving of self was an important measure of nurses caring. One student defined caring as the unselfish extension of ones self. Another stated that a nurse who does not care about anything but her/himself will not be concerned for a patient. Several students discussed going the extra mile to help in any way possible. Others described a more angelic perception of nurses caring, noting that nurses care for a client or family of a client because you do so willingly, without hesitation, and a nurse who cares will do what needs to be done to provide the best care for her patient. Valuing another was described by students as showing concern for patients well-being and empathy towards others. One explained that caring was an attitude toward others and clients need to feel that nurses care.It seems to be one of the easiest skills of nursing.Just being with someone can show that you care and respect and want to understand their situation. Others added the following responses: [Caring] helps a patient feel better [Caring] is important when the nurse has to provide unfavorable information. By taking a few extra minutes, we can give our patients a feeling of importance Additionally, one student wrote, I believe nurses are the number one most trusted profession because of their ability to care for each patient. In summary, these students freely explained why they chose nursing as their profession. They also identified the need for both competence and caring on the part of the nurse.
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