NurrrEducafrun T&y (1989)9,327-334 0 Longman Group UK Ltd 1989

02606917189/0009-0327/$10.00

An exercise in curriculum development - the process of putting theory into practice

Susan Simmons

Many nurses coming on post-registration courses have widely varying backgrounds and levels of experience. In addition they seek to develop their knowledge base and therapeutic skills, as well as address their personal and professional development. As adult learners they may have a clear idea of their own objectives for the course, and will often benefit most from a student-centred approach to learning.

This paper describes the process of reviewing and redesigning a post-registration course in community psychiatric nursing, using this knowledge and a curriculum development model as a starting point. The review particularly addressed the role and influence of student assessment, and the concepts of integration within the curriculum, and student/teacher negotiation of elements of the course.

INTRODUCTION

Since 1974 North East London Polytechnic (NELP) has run a post-registration course in community psychiatric nursing approved by the English National Board (ENB). In recent years this has been a 9 month course for Registered Mental Nurses who have an interest in working in the community. It involves both college based teaching and clinical placements.

The course designed in relation to the most recent ENB outline syllabus (Course number 8 11 - The nursing care of mentally ill people in the community) was approved in 1986 for a period of 3 years, and thus the approval was due to expire at the end of the academic year

Susan Simmons BSc (Sot SC) MSc RMN RGN Senior Lecturer, Department of Medical Sciences and Health Studies, North East London Polytechnic, Romford Road, London El 5 4LZ (Requests for reprints to SS) Manuscript accepted 6 February 1989

1988189. So that we would begin the process of resubmission in good time the course committee in October 1987 agreed that a review should be started immediately. A planning group was set up comprising three members of the teaching team, the head of department and four co-opted ‘outsiders’ from the field of community psychia- tric nursing. This group would be a sub-group of the course committee and would report to the . committee regularly.

In this article the author intends to discuss the main issues and problems which that review examined and to explore the processes which were involved in attempting to arrive at solutions.

THE PLANNING GROUP’S FIRST STEPS

The first stage of the planning group’s work entailed the identification of changes-in society,

327

328 NURSE EDUCATION TODAY

in mental health services, in the work of Com- munity Psychiatric Nurses (CPNs), and in the background and expectations of those coming on the course, (Stephenson 1986). We also discussed and agreed a statement on the role of the CPN.

Since the task was not to design a completely new course, but rather to revise an existing one, the planning group agreed at an early stage that it would be essential to identify the strengths of the current course and build on them. AS a result many features of the course remained the same or were subject to only small revisions.

However there were several separate, but linked, problem areas identified by the course planning group. Some of these related to the CPN course in general and appear to arise almost wherever the course is located, while others were specific to the course at NELP. Three of these areas of concern are discussed below.

1.) The first problem concerns the balance of the course between theory and practice, knowledge and skills. An ENB outline syllabus for a course in community psy- chiatric nursing has been in existence since the early 1970s. Initially this syllabus tended to be knowledge orientated, and courses required students to do a great deal of largely academic work, relatively unrelated to their practice. During this period the role of the community psychia- tric nurse (CPN) was developing rapidly, with much more work being undertaken with people who had not previously been in contact with psychiatric services and who required counselling or other forms of skilled therapeutic interventions. The work of CPNs was changing and it was essential that their education reflected these changes. Some research in the early 1980s demonstrated that CPNs often felt inadequately prepared for their role, and worse, those who had completed the ENB course (which is not mandatory) were no more confident than those who had not, (Skidmore & Friend 1984). It seemed that

2)

the CPN course was not meeting the needs of CPNs.

As a consequence of this and other reports the latest syllabus, published in 1985, stresses the need for the course to be skills-based, albeit for the skills to be built upon a sound knowledge base, (ENB 1985). However, despite this new syllabus and the injunctions of the validating body, students at NELP and elsewhere appeared to consistently say that they found that they did not develop sufficient skills to carry out their developing role.

There was evidence that students coming on the course continued to see this as one area on which they wished to focus. In July 1987 we held a Briefing Day for students who were coming on the course in September 1987. Towards the end of the day we asked them to form small groups and to discuss what their expectations of the course were and what they hoped to gain from it. Here are some of their comments:

applying theory to practice confidence building improvement of skills widen knowledge base identifying personal weaknesses and

strengths more structured in ways of working acquiring and developing skills developing a more psychosocial

approach evaluating interventions types of therapeutic interventions

The second main area of concern was one which was more specific to the NELP course. It was felt by the course planning group, by the course committee and by the Assessment Board that the students were over-assessed. The 1986/87 students had completed 10 pieces of work, all of which had to be passed and some of which were fairly substantial assignments. This had been discussed by the course committee at the end of that year and some revisions had been made, so that the students would

NURSE EDUCATION TODAY 3%

complete eight assignments during 19871 88. As well as concern that the assessment load might still be too heavy we were

concerned that the nature of the work

might be too divorced from their work as CPNs. We wished to develop assignments which would require students to link

theory and practice more fully.

3) Finally it was felt important to recognise the marked range in the students’ back-

ground and experience. Some had already

been working as CPNs for many years prior to attending the course, while others had perhaps not worked in the community at all, but had come straight from a ward

setting, or from their basic training. The types of bases from which they worked

varied widely. In addition some had specialist roles, for example, working with

elderly people, with people with drug or alcohol problems, or in the field of rehabilitation, while others were generic. Still others had particular things they

hoped to get out of the course, while some had little in the way of preconceptions. We felt that we wished to go beyond simply recognising these differences and to build upon them to the benefit of each individual

student and of the student group as a whole.

HOW DID WE PROCEED?

The planning group contained four people who were from outside the polytechnic (two practis-

ing CPNs and ex-students, one fieldwork teacher CPN, and one CPN service manager) and it therefore seemed appropriate that their role should be mainly advisory. The group met on a number of occasions over the following months and in between meetings, minutes and discuss- ion papers were circulated.

As already mentioned, it was of course also necessary to discuss our embryonic ideas with a number of other groups of people, in particular the rest of the teaching team, with current students and with fieldwork teachers (experi- enced CPNs who supervise the students during

their placements). With the teaching team there were discussions at the regular course committee

meetings, and a specially convened meeting in January 1987. Student representatives attended the course committee and were therefore able to

give feedback to the rest of the student group. We also used one of the scheduled seminar sessions (with the students’ agreement) to sound

out their opinions. There were also regular termly meetings with fieldwork teachers where our ideas were discussed in outline, and an extra

one in January 1988 devoted entirely to discuss- ing the proposals.

Finally a larger scale consultation with the students took place at the end of the second term through asking them to complete an evaluation

questionnaire. This seemed to be an appropriate

time to give them this, since they had finished the bulk of the college-based part of the course (the final term is mostly spent in supervised practice) and the data arising from it would also be useful

to inform the planning group if we were on the right lines. Twenty-one questionnaires were dis- tributed and 19 were returned. The results of

this questionnaire were analysed by hand and comments were summarised. The findings have been circulated to members of the teaching team and have already been used to inform the writing of a criticial appraisal of the course.

The ratings given to different elements of the

course and the comments made on the relevance and interest of different subjects, teaching meth- ods, assessment, and course organisation have

been extremely illuminating. Many comments were not surprising since they concerned things which I had already discussed with students, but the fact that a large number of the students came up with similar responses to a number of items on the questionnaire is certainly very helpful to the process of reviewing the course.

WHAT IDEAS DEVELOPED?

The working group looked at a number of issues including: course philosophy; course aims; the role of the community psychiatric nurse for which the students were being prepared; the course structure (in particular the balance

330 NURSE EDUCATION TODAY

LEARNING EXPERIENCES

Fig 1 Model illustrating the inter-relatedness of four main components

between college and placement); and teaching experiences and approaches. However there were some issues which we focused more sharply and which presented more of a challenge, and it is these that are discussed below. It was sug- gested earlier that the three main problem areas identified were separate but linked.

Assessment

Many writers on curriculum development have proposed models which they suggest illustrate the way in which development should take place. Such models vary in complexity but all usually contain the following elements: aims and objectives, content, structure, and evaluation. The more recent models point out that the process of curriculum development must be circular, while others describe it as iterative, i.e. repeating with all elements linked to all other elements. For example, Kerr (1968) proposes a very simple model (although it may be developed into something more complex if necessary): The model illustrates the inter- relatedness of the four main components, and also as Kerr points out indicates the four basic areas to be addressed in curriculum develop- ment (Fig 1).

Such a model need not only prescribe a process of curriculum development, but may also tell us something about how the course is conceptualised, or experienced, by students and teaching staff.

The planning group agreed with the com- ments of students and ex-students that the

course was indeed not sufficiently orientated towards therapeutic skills and that this part needed to be strengthened. However the model of the relationships between curriculum elements suggested that bringing this about would be more complex than simply putting more skills teaching into the course. During the 1987188 academic year, a number of students were becoming particularly anxious about certain pieces of assessment to the detriment of other sections of the course. The areas which caused most anxiety included the research pro- ject which required them to carry out a small piece of empirical research, and the social policy essay. Both of these pieces of work were fairly removed from their day-to-day work as CPNs and could be said to lie towards the theoretical/ academic end of the theory/practice continuum. Perhaps ironically the sections of the course which were neglected as a result of this anxiety appeared to be the more skills-orientated parts of the course, possibly because they were not for- mally assessed and therefore could be more easily skimped without major repercussions. This resulted in some students not attending such sessions on a regular basis or, even if they attended, not committing much energy or extra time to the work involved.

Rowntree (1981) describes a similar process whereby students come on a course for reasons to do with personal growth and development (something which seems particularly apposite for CPNs and was reflected in their pre-course expectations), but get hooked into a ‘games-play- ing metaphor’, in which they identify the parts of the course which are essential for assessment purposes and work hard at these, while neg- lecting their own original aims. In other words they play what they see to be the lecturers’ or the institution’s game, favouring rote learning rather than understanding and even

Side-stepping challenging topics or assignments,

even though they might seem to offer valuable

insights or help in their weak areas, in favour of

activities that make demands only on capacities that

they know they possess already. ’ (Rowntree 198 1)

The impression was that this, perhaps in a

NURSE EDUCATION TODAY 33 1

link the assignments more closely to practice. This would entail having only five or six pieces of work, a number of them which would require the student to integrate different elements of the course within an assignment. The most striking changes concern the research project and the individual subject essays (in sociology, social policy and principles and practice of community psychiatric nursing). Instead of requiring students to carry out an empirical piece of research we proposed changing this to a project in which the students would investigate a topic of their own choice in the field of community

KNOWLEDGE LEARNING mental health in whatever way was most appro- EXPERIENCES priate. This therefore may, or may not, involve

empirical data collection. Research would then

Fig 2 5 elements of curriculum be brought into the course in the form of looking at existing research in the field and developing research understanding and awareness. The

milder form, was happening to some students on the CPN course.

Clearly the form of the assessment could fundamentally affect the ways in which students and teaching staff think about the course.

Earlier it was mentioned how, according to Kerr’s model, changing one element of the curriculum will lead to the necessity and the inevitability of change in other areas. However in his model there is no separate assessment component, instead it is thought to be part of course evaluation and learning experiences, and to address course aims. However it was felt that assessment and evaluation - although linked in that student assessment is one part of course evaluation - for the purposes of our thinking about this course should be thought about as two different elements (Fig 2).

Clearly any of the five elements in the model has an influence on the others, and if any is altered it will have implications for the others. If the aims and assessment on our course are

subject essays would be integrated into one extended assignment, which would link observa- tions and notes from fieldwork placement with theory covered in college. As well as making the assessment load more relevant it was hoped that this proposal would lead to the students feeling freer to put more energy into the therapeutic skills elements without experiencing undue anxiety about assessment.

In addition to these changes the planning group also considered that further progress could be made along the road of strengthening the skills elements by further developing the assessment of these. Therapeutic skills are already assessed by fieldwork teachers and supervisors of placements, but are not systema- tically assessed in college. It was decided that the first step should be to develop a self or peer rating scale which the students could use in both college sessions and in fieldwork placement. It is hoped to use such a rating scale with the next intake of students.

altered they will and must lead to changes in content and organisation and this will be

Integration

reflected in the evaluation both formative and A second proposal was that the assignments summative. should require the students to link different

One of the first proposals for change con- elements of the course in relation to their work as sidered by the planning group was therefore CPNs, so that subjects would not simply be seen that we should reduce the assessment load and as separate, and possibly having little relevance

332 NURSE EDUCATION TODAY

to their work, but as each having something different but complementary to contribute to

the development of their knowledge base, pro- fessional development and skills. Kelly (1977) has described some of the processes and prob- lems in integrating sections within a curriculum.

He describes the different constraints on attempts to integrate different disciplines and different subjects. If areas of knowledge belong to different disciplines, e.g. mathematics and humanities, or science and arts, then integration may be very difficult and possibly artificial and unsuccessful. However if the taught areas are simply different subjects within one discipline, e.g. arts and languages; or biology and chemistry; then integration is much more straightforward. He quotes Dewey who argued that all knowledge is ultimately reducible to one form of scientific knowledge, and that we have simply organised it into convenient fields which have social and personal relevance. There is, if we accept Dewey’s argument, nothing fixed or God-given about the ways in which different subjects are categorised. Rather our notions of

the different subjects of literature, mathematics, science, history, philosophy and so on are social

constructs.

‘Knowledge is socially constructed or at least

organised to achieve certain social purposes. ’ (Kelly 1977)

One effect of attempts to integrate different subjects in one curriculum is that there is, according to Kelly, a shift from ‘out-there, God- given’ knowledge to common-sense, relevant knowledge, and that students are much more able to perceive the relevance and learn from it.

Many writers on the adult learner (Knowles 1984) have stressed the importance of the rele- vance, both professional and personal, of subject matter in facilitating learning. In addition Kelly suggests that many contemporary issues and

problems do not neatly fall into the domain of a single subject area-instead a number of subjects may have something to contribute to the under- standing of it. In the case of the course being discussed here such issues could include un- employment and mental ill health, or the development and meaning of community care.

An issue or a group of issues may then be conceptualised as a theme, which a number of subjects may address.

This is certainly relevant to the CPN course, in which the students currently study, in a poten-

tially rather fragmented way, a number of subjects which fall into the social sciences dis-

cipline. Not only would a thematic organisation of content help them to make links, but it would also probably encourage them to share more with each other - knowledge would no longer be ‘private property’. However if we wished to ask

them to integrate their assessed work by bring- ing different subjects together then it would also be important that the teaching team considered the way in which we taught those subjects. The planning group therefore looked at the possi- bility of bringing together the taught subject

areas into several themes, and having these themes reflected in the assessed work. There

would be five main themes to the course, most of which would be addressed by several subjects, and each subject would address more than one theme. (Fig 3).

Such linking of subjects would of course entail greater communication and co-operation among the teaching team and would provide less

opportunity for subject isolation. There are, not surprisingly, some problems. Kelly points out that some members of staff may feel that they could lose the identity and security which they

derive from their subject, and that their own

subject is not being properly assessed. This approach will therefore require further work and discussion, and increased communication and shared working among the teaching team, as well as clear guidelines for all concerned.

Negotiation

Our third issue concerned the varied nature of the students and the need to design a course which allowed for some areas of negotiation so that all would get as much as they could from it. We discussed the possibility of having a totally individually negotiated curriculum for each student, but recognised that with our present resources that would not be possible, and further that it may not be educationally desirable for all

NURSE EDUCATION TODAY 333

SUBJECTS

Individual and family in society

Research Professional CPN development studies

Therapeutic skills

Fig 3 Subjects selected to themes in the Course for Community Psychiatric Nurses

students. Indeed a manual on educational

change produced by the ENB (1987) makes the point that negotiated learning contracts should be introduced in a small area of the curriculum first. We were however keen that there should be scope for some student-formulated sections to the course. It was eventually agreed that there

should be two elements to the course:

1) a core area which all students would address and which would be the larger part

of the course 2) an individually negotiated element which

would be designed by each student in

conjuction with her/his personal tutor and where appropriate fieldwork teacher. This would involve the students’ projects, some elements of fieldwork placement, and their input to seminars in principles and practice of community psychiatric nursing.

WHERE HAVE WE GOT SO FAR?

The broad outline of the submission and a

critical appraisal (describing the rationale for the

proposals) now exist, although the submission requires further details to be included and for syllabuses for subject areas to be revised. The Course Document contains the details of the proposals, including a statement on course philosophy, course structure, themes and assess- ment. There have also been revisions made to

other course materials, for example, fieldwork teachers’ guidelines, assessment forms, and evaluation strategies, which have not as yet involved the planning group, but will become

part of the course submission document.

CONCLUSION

An attempt has been made to describe the process of redesigning a course in a way which might address some problems identified by students, staff and others. In particular these

problem areas included:

1) the balance between theory and practice, knowledge and skills

334

2)

3)

NURSE EDUCATION TODAY

the need for balance in the assessment requirements

the need for recognition and development of the positive benefits of students’ differences

It is impossible to say whether we have achieved these aims since we have not yet run this course and will not be able to do so in its entirety until 1989. However there is some reason to believe that we have moved some way in the desired direction. Student feedback has been very posi- tive both through student representatives at the course committee and through informal discuss- ions. Some of the changes will be implemented, with the ENB’s agreement, during the coming academic year. They will of course be fully evaluated, as will the full course once it is imnfemented in 1989.

Acknowledgements

I would like to thank the members of the planning group, and Gill Black and Roger Croot for their helpful com- ments on a draft of this paper.

References

English National Board 1985 Nursing care of mentally ill people in the community. Outline Syllabus, ENB

English National Board 1987 Managing change in &sing education. ENB - - -

Kellv A V 1977 The curriculum. Harner & Row Kerr J F 1968 The problem of curricilum reform in

Kerr (ed). Changing the curriculum. Hodder (L Stoughton

Knowles, M 1984 The adult learner: a neglected species. Gulf

Rowntree D 1981 Developing courses for students. Harper & Row

Skidmore D, Friend W 1984 Muddling through. Community Outlook, August 1984

Stephenson M E 1986 Curriculum development in action. Nurse Education Todav 6, 263-269.