CURRICULUM IN CLINICAL EDUCATION – WHAT IS IT AND WHY IS IT IMPORTANT?
I took a couple months off from writing blogs due to a very busy summer with a full teaching and consulting workload, so I am excited to restart the blogs. Over the last few months, I've had many conversations with some of my colleagues across the country regarding NP postgraduate residencies and fellowships, including academicians from esteemed universities who are my consulting clients. Through these conversations, I have realized that there isn't a consensus in the definition and practice of "Curriculum" in NP clinical education. There is a misconception that curriculum in clinical education comprises almost entirely of didactic education coupled with evaluation. In reality, the majority of the curriculum of an NP postgraduate residency or fellowship is clinical practice. Is this lack of consensus a surprise? Not really. NP postgraduate education is still a young concept without much peer-reviewed literature to support (or refute) it. So I've invited an esteemed colleague and a dear friend to guest write a blog post. Dr. Candice Rettie has had 40+ years of experience as an academician, clinician, and administrator. With her experience as the former Executive Director for NNPRFTC, and as the Vice President for Education for the former University of Maryland Biotechnology Institute, she is sharing some of her wisdom below.
DoQuyen Huynh, DNP, FNP
Guest Author: Candice S. Rettie, PhD
Executive Director (Retired)
National Nurse Practitioner Residency and Fellowship Training Consortium
August 2020
Over the years, Dr. Huynh and I have had many invigorating conversations about curriculum. We explored what it is, what it isn’t, and why curricula are the cornerstone of well-designed postgraduate residencies and fellowships. Frequently, I was reminded of other discussions with various colleagues -- health professions education researchers, residency/fellowship faculty and administrators, fellow committee members of national, university, school, and departmental curriculum committees. So it was with great pleasure that I accepted Dr. Huynh’s invitation to write this August 2020 blog for Bridgestone Consulting, exploring definitions of curriculum and its foundational role in a residency or fellowship program.
The Institute of Medicine’s 2011 publication: “The Future of Nursing: Leading Change, Advancing Health” described the need and provided the guidelines for postgraduate nursing education learning environments. This was followed by the 2018, Josiah Macy Jr. Foundation’s conference “Improving environments for learning in the health professions”, which described learning environments as:
“Learning environments (LEs) are created when people come together to share knowledge, skills, and information to improve the performance of all involved. These environments can be formal or informal and occur within a particular social, organizational, physical, and/or virtual setting. Learning environments comprise a wide array of structures and formats within organizations that vary by purpose, scope, size, location, availability of resources, leadership, and infrastructure.”
During my 40-year career as a health professions academician, educator and consultant, I have frequently encountered questions from residency directors, faculty, preceptors and deans about how to design effective and relevant learning environments. Their questions usually include asking about curricula. They ask: “What, specifically, is a curriculum? “Isn’t it a schedule of presentations, and lectures and on-line learning?” “Why does a curriculum need to be written down when we’ve got the schedule?” “We don’t worry about the clinical rotations. They are separate from the curriculum. Each clinic manages it; the preceptor/clinical faculty there have years of experience. They’ve taught all kinds of students. They know what they are doing.”
Let’s identify some of the unspoken assumptions behind these statements.
1. The schedule of formal “classroom” learning (eg: lectures, grand rounds, journal club) constitutes the curriculum.
2. Clinical or experiential learning is the purview of the individual supervising clinician or faculty member.
3. Qualified clinical faculty or preceptors will ensure that all the learners have comparable opportunities to master the same set of skills, attitudes and knowledge and develop the same scope of practice. Essentially, every faculty member or supervisor has the same approach to facilitating the same level of mastery, ensuring comparable clinical learning opportunities, focusing on the same set of specific learning outcomes, using the same assessment and evaluation protocols.
These assumptions invariably reflect the best of intentions. However, they are not supported by consensus-based best practices in postgraduate education, scholarly educational research, nor real world experiences in designing and delivering healthcare professions residencies and fellowships.
Creating a schedule of formal learning experiences certainly is one way to begin designing a curriculum. Nevertheless, a well-designed curriculum that will propel a resident or fellow from entry to successful completion is, and must be, so much more.
So what is a curriculum anyway? Does it include clinical experiences, independent study, community service, capstone projects? Who is the curriculum for – is it just the learner? Why do clinical experiences and faculty need to follow a curriculum? Is there any evidence that having a formal curriculum makes a difference?
The curriculum provides a comprehensive, meaningful approach to learning. The curriculum is an explicit document that provides a shared understanding and means for delivering the residency’s the core values, philosophy of care and learning objectives. The resident’s scope of independent practice, discipline/specialty-specific specific knowledge, skills and attitudes are all identified and operationally defined.
A curriculum provides a comprehensive, yet detailed plan for a purposeful learning environment. A well-designed curriculum lays out a learning experience that is consistent with: the values of the organization, the philosophy of the profession, and the current evidence and best practices of the profession. A curriculum is a formal, written and shared document that everyone who is involved in the program should know and understand. It assures consistency of learning opportunities and teaching approaches by providing specific learning objectives and short-term and long term goals. A well-designed curriculum also provides specific metrics that allow its effectiveness to be measured. Comprehensive, consistent and meaningful assessment/evaluation processes use the metrics to provide feedback to the learner, the faculty, the program and the sponsoring institution. A curriculum provides a mechanism for reliable documentation that yields valid indicators of accountability, quality improvement, as well as learner and programmatic growth.
As the Executive Director of the National Nurse Practitioner Residency and Fellowship Training Consortium I authored a series of blogs on curricula: definition and role of a curriculum; designing curriculum; learning objectives and crosswalking the curriculum with evaluation. Below is an excerpt from the first blog in the series:
“The curriculum is the program’s map, laying out the journey step by step. The curriculum should be designed to provide mission-relevant experiential learning so that the ‘learner’ acquires knowledge, attitudes and skills, through various methods and media such as didactics and experiential learning that includes hands-on practice and performance-based instruction. The curriculum is divided into competencies or domains that describe global, higher-level, workforce relevant accomplishments that are demonstrated upon completion of the program. Competencies provide benchmarks that are operationalized into objectives. The components of the competencies are defined by objectives that measure specific knowledge, attitudes, and skills. The objectives are important and relevant examples of what we want the learners to know or do.”
Let’s spend a moment on the clinical component of a curriculum.
A residency is not an apprenticeship with a talented and insightful clinician. Residents have already mastered the foundational knowledge and clinical skills of the discipline. The goal of the residency is to expand the knowledge base and hone the clinical expertise of the learners. Therefore, the clinical experience comprises the vast majority of the curriculum. The clinical experience needs to have clearly defined learning opportunities, each with specific learning goals paired with measureable outcomes that reflect the philosophy and values of the sponsoring institution. The learning opportunities should foster the resident’s increasing mastery and expertise of higher level, specialty-specific competencies. The ultimate goal of a residency is to contribute to the residents’ growing professional identity, expertise, and confidence as competent practitioners. So, a curriculum is the essential, written roadmap for how to accomplish all the components of that lofty goal.
There is a long tradition of scholarship and application of curriculum design, development, implementation and measurement of effectiveness in the health professions. There are troves of scholarly organizations, funded research, peer reviewed publications, and best practices on curriculum development. Check out North Central University’s library for a listing of scholarly publications, journals, practical guidelines and other resources. An excellent scholarly reference book on current research and best practices in curriculum development is The SAGE Handbook of Curriculum, Pedagogy and Assessment, 1st Edition by Dominic Wyse, Louise Hayward and Jessica Pandya (2016).
In the 2005 revision of their classic 1998 text on curriculum design, “Understanding by Design”, Wiggins and McTighe summarized the value of a curriculum.
“Curriculum shares a common philosophy of learning that emphasizes learner understanding and application, not just knowledge or recall. A curriculum is anything that directly impacts a learner. Curriculum cues preceptors and mentors into the big ideas and the essential questions of each content area.”
Another useful description of curriculum is provided by Al-Eyd et al in their 2018 article:
“A curriculum symbolizes the expression of learning and teaching designs in practice. Harden defines the curriculum as “a sophisticated blend of educational strategies, course content, learning outcomes, educational experiences, assessment, the educational environment and the individual students’ learning style, personal timetable and programme of work”. A curriculum must be designed such that it is easily communicated to both the students and the faculty, and be effortlessly reviewed, evaluated, and revised once it has been implemented into practice.”
While Al-Eyd’s article focuses on curriculum development for a new medical school, the principles are universal (eg: Prideaux, 2003; Harden, 2001) and easily transferrable to NP postgraduate training.
How is all of this relevant to an NP postgraduate residency, 80% of which is clinical learning? In McKay et al’s (2017) study, “Nurse practitioner residency programs and transition to practice”, novice NPs identified the following clinical areas where they felt unprepared: independent decision making, time management, complex care, prescribing, interdisciplinary communication, minor office procedures, and billing coding. We’ve all seen resident hone their clinical skills over the course of a year. Kathryn Rugen and her colleagues at the US Department of Veterans Affairs have published two studies investigating the efficacy of clinical competencies as defined in their residency curriculum: one investigating the effectiveness of an NP residency (and its curriculum) and one comparing resident self-reports of clinical competency with faculty evaluations. Clinical competency is the ultimate objective of a residency; well-defined clinical competencies must be the foundation of an NP postgraduate residency’s curriculum.
To summarize, a curriculum is a road map, a recipe, a detailed travel guide that describes the entirety of the learning experience, lectures, clinical, independent study, projects, etc. It guides everyone who is involved in the delivery of educational or training program. It is designed to address the roles and expectations of all the participants (learners, ‘teachers’, facilitators). It specifies the teaching/learning approaches as well as the required resources, including administrative and operational support. The best way to get where you are going is to know where you want to end up. Curricula tell you where you are going and how to get there.
References:
2. Josiah Macy Jr. Foundation. Conference summary: Improving environments for learning in the health professions. Josiah Macy Jr. Foundation. 2018. http://macyfoundation.org/publications/publication/conference-summary-improving-environments-for-learning-in-the-health-profes
4. Iwasiw, C. L., Andrusyszyn, M., & Goldenburg, D. Curriculum Development in Nursing, Chapter 1: “Introduction to Curriculum Development in Nursing Education: The Evidence-Informed, Context-Relevant, Unified Curriculum”. Jones and Barlett Learning, LLC. http://samples.jbpub.com/9781284026269/9781284026269_CH01_PASS03.pdf
5. Parkay, F.W., Anctil, E.J., & Hass, G. (2010) Curriculum leadership: Readings for developing quality educational programs. Boston: Allyn & Bacon.
6. Al-Eyd, G., Achike, F., Agarwal, M. et al. Curriculum mapping as a tool to facilitate curriculum development: a new School of Medicine experience. BMC Med Educ 18, 185 (2018). https://doi.org/10.1186/s12909-018-1289-9.
7. Prideaux D. Curriculum design. Br Med J. 2003;326(7383):268–70.
10. Rettie, C. “Chapter 4: Nurse Practitioner Residency Program Structure and Curriculum” in Flinter, M. and Bamrick, K. (Eds). Training the next generation: Residency and fellowship programs for nurse practitioners in community health centers. 2018.
11. Rugen, K. W., Dolansky, M.A., Dulay, M., King, S., Harada, N. Evaluation of Veterans Affairs primary care nurse practitioner residency: Achievement of competencies. Nursing Outlook. 66(1):25-34, JANUARY 01, 2018. https://doi.org/10.1016/j.outlook.2017.06.004
12. Rugen, K. W., Harada, N., Harrington, F., Dolansky, M.A., Bowen, J. Nurse Practitioner residents' perceptions of competency development during a year-long immersion in Veterans Affairs primary care. Nursing Outlook. 66(4):352-364, JULY 01, 2018. https://doi.org/10.1016/j.outlook.2018.