Nurse-Education Tcdq (1992) 14,310-315 @ Longman Group UK Ltd 1992

An integrated approach to curriculum development

Susan Simmons and Daman Bahl

This paper explores some aspects of what is meant by integration in a nursing curriculum, by looking at both integration of course content and subject matter, and a consequent move away from separated academic disciplines towards a thematic approach, and at integration of the student group, so that different groups of nurse learners study and learn together for a certain proportion of the programme.

We consider reasons for adopting an integrated approach by discussion: issues related to learners and the learning context (these include theories of how adults learn and our perspective on the part to be played by experiential learning); the potential implications for client/patient care and the need for transferable skills to work as a member of a team; and staff development for the teachers, including moves away from possible isolation towards team-teaching. We then go on to describe a model for curriculum development devised in our own institution and based on these principles, which incorporates the development of learners professionally, educationally and personally.

This paper discusses the topic from a mainly theoretical perspective, and many of the issues will be relevant to a wide range of courses.

INTRODUCTION

Integration has become something of a buzz-

word within nurse education in recent years. But

what is normally meant by this concept, and why

is it considered worthwhile? In this article we

propose to explore the meaning of integration,

the reasons we chose to develop an integrated

approach to curriculum development, and the

Susan Simmons BSc MSc RGN RMN CertEd, Principal Lecturer and Daman Bahl BA MSc RGN HV, HV Tutor, Head of Nursing Development, Polytechnic of East London, Department of Health Studies, Ronford Road, London El5 4LZ. UK (Requests for offprints to SS) Manuscript accepted 17 March 1992

310

model which arose from our endeavours. This

paper will cover the theoretical background to

the development of an integrated curriculum,

and the discussion will therefore not be specific

to any particular course. The post-registration course arising from this integrated approach will

be described in a later paper.

What is integration?

In general terms integration is commonly used

to refer to the process of making something whole, unified or complete. An early description

of the concept within education comes from Tyler (1949), and has been picked up and

NURSE EDUCATION 'I‘ODA\ 311

related to nurse education

is echoed in the writing of those people

(Aggleton & Chalmers 1986, Pear- son & Vaughan 1986). There is a growing awareness that for too long in both nursing and nurse education there has been a splitting-up, a fragmentation which has imposed an artificial reality on the experience of people’s lives.

Within nurse education integration may, we suggest, refer to two main developments. First it can refer to an integration of the course content,

for many years. The course content has included

students addressing key issues in teaching and learning and preparing joint presentations on aspects of these issues, e.g. the community prac- tice teacher’s role in assessing students. Again students feedback and evaluation over the last 8 years has demonstrated how the combined nature of the course is a key, positive aspect for the students. This type of course has also aided staff development in relation to teaching from an inter-professional perspective.

so that previously separated academic disciplines are linked and links are made throughout WHY INTEGRATE?

between theory and practice. Second it can be used to indicate that the student group is made up of members from different branches of nursing or from nursing and another profession (for example, social work) and are learning together. Our thinking and planning incorpo- rated both of these ways of integrating and we shall discuss them below.

There are various reasons for integration within a post-registration course, many associated with the nature of adult learning. We shall discuss: learner issues and the learning context; the quality of patient/client care; and the pro- fessional development of teaching staff.

We have in fact had previous experience of using these approaches to integration in courses

Learner issues and the learning

at the polytechnic. On our three separate com- context

munity nursing* courses (health visitor, com- munity psychiatric nurse and district nurse) we had gradually developed shared teaching and learning in both sociology and social policy. In addition, we had set up issue-orientated shared workshops (e.g. on teamwork and primary health care), including the whole student group, gradually increasing the number of these each year. In their feedback students commented on the value of these parts of the courses, saying that they had increased knowledge of each others roles, and greater awareness and confi- dence in their own role. Issues to do with role boundaries and role overlap were also raised and addressed in these workshops.

On our Community Practice Teachers and Assessors courses students from the same three branches of nursing have been taught and have learned together for the major part of the time

*The term ‘community nurse’ is used as a generic term to denote nurses working in the community and health visitors.

After long neglect the adult learner has become a focus of study in recent years. Various writers have developed theories of how adults learn, perhaps the most famous of which is that of Knowles (1984) whose theory of andragogy has influenced nurse education. We cannot discuss his theory in depth here, but would like to refer to several key points. Knowles argued that adults learn most effectively by using their own experi- ence as a basis on which to build, that they constantly seek to make links between their experience and what they are learning, and that the relevance of what they are studying is par- ticularly important.

Adults do not experience the world and their work in terms of separate and fragmented academic disciplines, but as issues and themes which cut across such disciplines. For example issues such as unemployment and health, poverty, child abuse, or increasing numbers of elderly people, are more central to community nurses’ working lives than are the academic disciplines which have so much to contribute to

3 12 NURSE EDUCATION TODAY

our understanding of such issues, for example, psychology, sociology and social policy.

Townsend (1990) argues that problem-based learning can demonstrate that theory and prac- tice may be viewed as arising from a single source, rather than being two separate entities. By developing therefore a thematic approach to the study of key issues the students may draw on their own life and working experience, and also bring together the insights provided by research and theory to construct a unified and valuable understanding.

In an earlier paper, Simmons (1989) has discussed the potential constraints and benefits of subject integration. Kelly (1977) has argued that the way in which different types of know- ledge are currently categorised is a social con- struct, organised to achieve certain purposes. If the barriers between different fields of know-

sufficient time is given for review, reflection and planning. This has been described by Kilty in his experiential learning cycle (Kilty 1983). Exper- iential learning is, therefore, ‘any learning which increases the facilitation of experiential know- ledge’ (Burnard, 1989:301), i.e. personal know- ledge which cannot easily be transmitted to others.

A final learner issue which points to the value of an integrated curriculum is that of the students’ own professional development needs. It is essential that nurses are equipped with the skills to work with a range of other professionals. A course which requires and encourages them to do this in the day-to-day activities of their learning is providing them with something which could be very valuable.

The quality of patient/client care ledge are broken down we will, according to Kelly, arrive at a more common-sense, relevant

The main purpose of nurse education is to

body of knowledge. Such a development is improve the quality of care provided to clients

clearly of great potential value to nurse edu- and patients. It is now recognised that quality

cation. care is integrated, holistic care, which treats the

Knowles and others have also said that an individual as a whole being, and a being who

important outcome for which any education functions within a social setting which is vital to

should strive is the students’ ability and wish to her well-being. In much of health care nowa-

carry on learning once a particular course has days, both within hospital and community set-

finished. In relation to these points an integrated tings, the complexity of people’s lives and health

approach enables previous learning and experi- and social problems means that no single pro-

ence to be used as a foundation for future fession can meet all of their needs. Inter-pro-

learning and requires, allows for and facilitates fessional working has become essential, but it has

the students’ active participation in the creation also become important that there is flexibility

of their own learning environment, and helps and adaptability in any single profession’s role. It

them learn how to learn. is important then that nurse education should

Another important reason for an integrated provide students with the opportunity to learn a

approach is that it enables an emphasis to be put great deal about each others’ roles, but more

on experiential learning in the development of than that (since no single course can provide

the reflective practitioner (Schon 1983). students with knowledge of the roles of all

Burnard (1989) makes the point that experien- possible future colleagues) that it should give

tial learning is interpreted in quite varied ways students the trun.sferuble skills of teamwork and

by nurse teachers. By experiential learning we inter-professional cooperation.

refer to learning from and by experience in its many forms, within college-based units, within

Staff development

community practice placements and within the An integrated curriculum requires that staff too relationship between these two. We see that not change the way in which they work. There are only does theory inform practice, but that, in various implications. Although there will still be addition, experience derived from ‘hands-on’ teaching staff with expertise in particular disci- practice informs and develops theory, provided plines there will be the need to work closely with

SUKSE EDUCATION TODAY 3 13

other staff who will be addressing the same theme or issue from a different perspective.

Staff will no longer work in relative isolation, but team-teaching will be further developed. Although potentially threatening it is also an exciting opportunity, and will in future, we suggest, contribute to the development of a clearer staff ethos and culture, and be more supportive of individual staff.

THE CURRICULUM MODEL (THE PEP MODEL)

Continuing our theme of integration we derived a model which we believed incorporated the points raised above. We see post-registration as preparing and developing people in three main areas; professional, educational and personal. These three areas are, or course, inextricably linked, so that changes and development in one area will inevitably affect the person’s func- tioning in another. However it is still possible to examine what is meant by each one in turn.

Professional development

involved in decisions about their care, and that the public generally should be more fully informed about health care issues and about plans and proposals concerning service provi- sion. The term self-empowerment has been used

to describe this aim. Salvage (1990) has written about this change as the ‘new nursing’ which is underpinned by the philosophy of a working partnership between patient/client and nurse. and seeks to transform previous. traditional power relationships. However it must also be recognised that in order to help patients and clients become self-empowered the nurse too must become empowered. She must be able to take a critical, analytic and reHective view of situations, be able to be assertive on her own and her clients behalf, and be able to be responsible and accountable for her actions and decisions.

A further feature of professional develop- ment which wejudged as essential is (as referred to above) the ability to work collaboratively in a

team, and to be able to transfer those skills to any team in which the nurse finds herself a member. This will entail developing a clear concept of her own role (something which can be quite complex in community nursing) but maintaining this within flexible and adaptable parameters. In all

It is essential that nurse education at basic and of these issues then education can and should

post-registration level recognises and works with play a major part. the changing nature of society, and the changing systems and organisation of health care in Britain today. Change has, it appears, become the status quo (ENB 1987). In order to be able to meet the challenges presented by such changes nurses must not only have a sound working knowledge of what reorganisation, changes in the law, and changes in service provision actually entail, but they should also be able to develop a critical awareness of, and adaptability to, changes that have not yet taken place but will arise in their future working lives. Maura Hunt has commented that nurses rarely see them- selves as the instigators of change but rather the victims of it (Hunt, 1987). Education has an important role to play in redressing this situation.

A related issue concerns the changes in public awareness in health care and a growing consen- sus that patients and clients should be more

Educational development

There have been numerous changes in nurse education in recent years, most notably Project 2000 which is taking the preparation of nurses out of a training mode (focusing mainly on the acquisition of skills) and into an education mode (incorporating a ‘process which involves the whole person. . . it is about the growth, develop- ment and humanity of the person’ (Jarvis & Gibson 1985)). In addition the IJKCC is cur- rently looking at the educational and pro- fessional needs of already qualified nurses in its ‘PREPP’ proposals. One of the most striking educational differences between the new courses for nurses and the previous ones, are the links with the higher education setting, and the broader perspective which this ideally provides. No longer are nurses to be taught only with other

3 14 NURSE EDUCATION TODAY

nurses, safely cocooned from the outside world, but there will be a gradual shift towards a mixing with students from other courses within higher education. A further benefit of these courses and an acknowledgement of the level at which they are to operate is the Diploma of Higher Edu- cation which is incorporated. Many post-regist- ration community nursing courses are already run in higher education institutions, but any model for such education must now also lead to a course which is designed at diploma level or higher.

Related to this is the issue of the balance between education and training in post-regist- ration nurse education. In a discussion on the use of objectives in post-registration courses, Gerrish (1990) makes the point that nurses entering post-registration courses have very different educational needs, different experi- ences on which to draw, and varying expecta- tions of the course in relation to personal and professional growth. Clearly these differences need to be recognised and valued in any course design.

A less tangible aim of our model is to foster in the students a commitment to learning, so that the students become self-directed learners who take on responsibility for what and how they study, and as a result recognise the importance and rewards of life-long learning.

Personal development

The model we have developed (the PEP model) incorporates professional, educational and personal development and provides a framework to enable us to address the links between theory and practice which are para- mount in nursing education, and also to facilitate the development of the student in these three inter-related spheres. The ultimate aim is, as always, to improve client and patient care.

There are several aspects of personal develop- ment which go hand-in-hand with aspects of professional and educational development referred to above. A major aim encapsulated within our model is the development of confi- dence in the students, which in turn should lead to an increased ability to be self-empowered. Of course this relates to their confidence in their own growing professional skills, but it also refers to assertiveness, an ability to communicate effectively, and an ability to feel confident in accounting for professional decisions. There is also a confidence which appears to be derived from the benefits of the wider perspective of higher education which some nurses trained in

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Another important aim of our model is the development of self-awareness and the skills of self-evaluation. Only by acquiring and con- stantly using these skills will nurses become the reflective practitioners whom we see as essential to nursing in the future.

CONCLUSION

We have attempted to set out some of the main features of our approach to curriculum develop- ment using integration, both of the content and of the student group, as a theme. We have argued that both these forms of integration are particularly appropriate in the field of post- registration nurse education, to prepare a future thinking and competent practitioner, who will have the ability to work flexibly, as an equal member of a team, in partnership with her clients or patients, and with the skills and moti- vation to commit herself to her own life-long learning.

NURSE EDUCATIOK TODAY 3 15

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