Theoretical and Scientific Foundations of Nursing

Application of Theory Nursing Education Melanie McEwen and Evelyn M. Wills

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Linda Washington is a supervisor on o surgicol floor of a large teoching hospital. Her responsibilities require her to work closely with the foculty from two oreo nurs- ing schools ond help place students with preceptors. Because of her enjoyment in working with students ond foculty, Lindo decided thot she would like to become a nursing educator and enrolled in a moster's degree program. This semester, she is toking a course titled "Curriculum Development ond Evoluation," ond she is leorning a greot deol about how nursing programs ore structured ond the under- lying rotionole. The course requires o project in which a smoll group of students designs a nursing program thot will meet the chonging needs of the heolth core system ond the emerging profile of nursing students in the 21st century. lnitiolly, this project seemed daunting for Lindo ond her colleagues, ond they were unsure where to begin .

During one closs period, Lindo's professor explained how the curriculum of o nursing program is derived from the foculty's philosophy of nursing ond nursing educotion. She explained thot o conceptuol Framework is then developed from the philosophy, ond it is from this fromework thot the curriculum is built. The students olso leorned thot in most nursing programs, the conceptual framework is on eclectic blend of concepts and processes, although some programs use grand nursing theo- ries as their bosis.

In o broinstorming session, Lindo ond her group ogreed on a philosophy of nursing educotion, describing whot they sow as the interploy of the meloparodigm concepts ond concepts ond processes of leaching and learning. But there was con- sideroble discussion ond significant differences omong group members obout whot other concepts or theories should be used os the basis for the curriculum frame- work. In addition, there was disogreement on whot would be the best teaching strategies to meet the needs of older nursing students ond students from diverse backgrounds. Some members of the group fovored a structured, traditional type of program in which the faculty member was responsible for directing learning expe- riences, whereas other group members preferred to focus on less rigid instructional techniques and incorporote more web-based options ond simulotion.

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502 Unit IV Application of Theory in Nursing

The discussions were enlightening, and finally, tindo's group compromised. Tihey would 1use "coring" as o central concept and draw heavily from Jeon Watson's ( 199,6) work to structure tl,e curriculum. They would also incorporate adult learning principles ond technologically based instructional strategies into their program. With lhese parameters ,in p 'loce, the group began to describe courses, write objectives, outline course sequencing, discern outcome measures, identify teaching strategies, and set up evaluation methods.

The he.11th car,e dehery system 11:1~ changed dr.1111atic.1JI~· dming the pa~t I ii years. Nur~- ing practice 11.1.~ also changed, requiring it to adapt to trmsitioning from institution- b.1sed, ·,1cure c,u-e Lo more comnnmity-based care with ,111 enh,111ced focus on caring for older .1dults .rnd indi,·idu.1b \\·ith chronic condition.-; ,1$ \\·ell .1~ understanding thc impon.111cc of cult11r.1I ditfrn:ncc~. Nur~ing l.'duc.uiun, too, mti.~t ,HiJpt to ch,rnge~ .rnd .mticip.1tcd trcnd~ in he.11th c.uc .md cducation. htrthermore, nursing lc.1dcrs .md nmsing org.mizatiom ,d10 belie,~· that '"it is the responsibility of nur~ing education, in coll.1bor.uion with pr;1cticc settings, to .~hapc practice, not merely re~pond to ch.mges in thc pr,1cr,ice cm·ironmcnt" ( Amcric.m .\s~oci.1tinn of Colleges of Nur~ing I A.\C;\' ], 1999, p. 60).

Th.: lircr-.. uure i1- .1w .. 1sh wirh bunwon.h for nur~ing education. Probkm-based le.1rning, lifrlong learning, informati.:-S, ... -,·idence-hased education, quality/p.:rformancc imprm·em.:nt, ,:ompetency-b,1s1..•d eunicul.i, cultur.1lly rd.:vanr cJ.r.:, sen-ice learning, intcrperson.11 com111unic.1tion, J.nd cxcdkncc .uc only a frw. Furthermore, new trends for curricub rdkct increased e111ph,1sis on evidence-b.1sed practice, popubtinn diver- 5ity, patienr outrnmes, hrnlrh promotion, genetics, ,rnd inform.1tics (Muclkr, 2016; Pressler & Kennc::r, 2015; Spcziak &: Jacobson. 200S }. Other ernlving emphases in nursing cduc,uion include .1 greatc::r fonts 011 economic~ nt he·,1lth care, incre.1sing use of simubrion, along wi,th more .1n.:ntion to intcrprofr~sion.1I cducational coll.tbor.1- tions ,111d disi:-.11,ce education I !nstitutl' of i\lcdicine I IOJ\•\ ]. 201 l; Keating, 2015a; O'Ncil, 2015).

'1n general term~. rheorctic.11 principles, conccpts, ,111d models .ire used in rwo m,1jor w,1y~ in nursing ,education. hrst, they .1rc u~ed to dctcrmine thc content ,rnd organization and ~tructurc of.1 program\ curriculum. Second, they ,1rc med to deter- mine the instruction,11 proce.,scs .rnd str,1t1..·gie~ usc::d by facultY to tc.ich students. Both of thc,e contributiom of theory to nursing education .ue discussnl in thi~ ch,1pter.

Theoretical Issues in Nursing Curricula Curriculum rdcr~ to the colllent .md prt>L·e~se5 by which lc.uner~ gain k.nowkdg.1..· and undcrsranding; d1..·,·clop ~kills; and .1lter .1ttitude~, .1ppreci.1tion, .rnd ,-.,lues undcr the auspice~ of.1 giYen ,dwul or program. The curricu,lum of.l ~dmol of nursing typically includcs philosophy .md mis~ion sr.ncmcnt5; .rn org.111izati01ul or cunceptu.11 frame· work.; li$ts of outcome5, competeneics, .md objective~ for the program; individual cour~c::1,, cour e outlinc, .md ~~·ll.1bi; eJuc,Jtional ,Kti,·itics; .md c,·,1luation method!! (Sulli\',\11, 2016). furthermore, most nursing curricula speci~· essential nursing con· rcnr .md means of .1pplication in dinical practice ( Keating, 2015b ). Spc::cilic compo- nent~ of the curriculum 0L1 given program of study .ire ~ummarized in Box 22- l.

Se,·er.11 issue~ th.a relate to the incorporation of ,thcoreric~11 principle::~ and fr.rn,e· works into nursing curricula .. 1re rcviewed in thi~ ~ection. Thc~e include b.1~ic curricu- lum design, rhe impact of regul.ning org.miz.itions on nursing curricul.1, componcnt~

Chapter 22 Application of Theory in Nursimg 1Education 503

Box 22-1 Components of a Curricdlum

A defimed phi losophy or mission stolement An orgonizfr19 framework Ant.icipaled outcomes, competencies, end/or objectives to be ochieved Selected content with specific sequencing of t~e conlent Educational activities and experiences ,to fadlitate leoming Meons of evoluotion

Source: Sullivan {2016).

of currin1br conceptual/organizational fr,urn:works, :rnd the processes innJh·cd in designing .rnd orgJnizing nursing i:urricul,1. The ~ci:tion i:ondudcs with .1 short dis- t:ussion oft:urrent issues in nur,ing currintlum development.

Cuirrirnlum Design in Nurs1in,g Educatio:n :\ wrriw/11111 is a "formal plan of study that provides the philosophical underpin- nings, goals, and guidclines for the dc.:lin:ry of a specific l"ducationaJ program I Ke;1ting, 2015a, p. l ). The currirnlum pnwidcs faculty with .1 means of conceptual- izing .md org.mizing the knowledge, skills, \'alue!., and bclidi; critkal to the deli\'Cry of .1 coherent program of study th.u fat:i,lit.He~ the achic\'emt'nt of the desired outcomes ( Rud1.1la, 2015; Sullivan, 2016).

The n1rri.:u!J of most nur~ing programs arc bas<.·d on the Tylc.:r C urriculum Dc\·elopment !\lodel, \\-hich was published in 19-:1-9. Bc.:,·is ( i989a, 1989b) stated that thc incorporation of the Tyler model \\'ithin nursing t:urrkula began in the l 950s and rnnrinucd through our the l 960s .md 1970s. According to Bc\·is (l 989b ), in- troduction of Tyler's concepts in the I 950s, along "·ith her first book on curriculum dt',·elopmcnt ( Be\'is, 197 3 l and lager's { 1962) publi..:,1tion of Pnpnring lllstmc· tio1111l O~fcctiPcs, led to the de,·elopment of Tykr-typc.: curricula throughout nursing <.'dut:ation. E\'cntually, the Tyler model became: the prim:u·~· model used in dt'n:loping nursing currin1h for .• 111 k\'els of 1wr~ing cd11cation-diplom~1. associate degree, and b.Kc.1l.rnrc.:.1te.

The Tyler model bcgins \\',ith idcntitication of the education.ii purposes or ob- jecti\'I:~ for the program. It thrn ditfrrentiares what lt'.1rning experience~ should be selected to .n,.1in tht' objecti\'cs. The third issue Jddressc.:d by the Tylc.:r model is how to organize learning expericncl.'s for dli..·ctin: instruction. Finally, the model focuses on <.'valt,1\1tion of behaviors tn dc.:tc.:rminc ifobjecti\·cs h.we been met (Bevis, 1989b). Tht: Tyler mode:'! nlues eftcctivc.:nc.:ss, efficiency, and predictability, and it emphasizes indi"idu.1l i\m .rnd competition. It .l!>Sumes that knowledge consists of facts, general- izations, principlei., and thcoric~ :tnd that events or phenomena ..::111 be expl,uned by c.n1se-.md-eft~ct relationships tl1.1t can be deductivc.:ly ex,1mined.

Nur·sing Cuirrku'la and R,egulating Bodies The imp.Kt of tJ1I.' Tylc.:r mndc.:1 on nursing nmi.:ul,1 ,llld nursing education c.umot lx on:rstmed; it has directly influenc,ed tlot only the .st:,1'tc boards of nursing bur .1lso tlw J.ccrcditation process. St.ire boards of nursing St't rules and requircmt'nts reg.1rding nur.,ing educational pmgrami. and curricul.i; tJ1csc boards e,·cnru.llly based critt'ria for lic<.:nsure of nursing pn>gr.um on cl1c Tyler model ( Bevis, 1987; Rentschler & Spegman, 1996).

504 Unit IV Application of Theory in Nursing

According to Be\·i~ ( 1989h ), the ·1\kr-based curriculum de\·dopment pmcc~~ lus been tran~l.ncd into es~cntia.l currinil.1r compon.:nt,, and without c,·id.:ncc of these component~, sr.m: board~ \\'ill nor gr.mt progr.1111 a.ppro,·al. The rule~ .rnd reg- ulations set by state bo:irds of nursing rypic.1lly spel.'.ify 1.'.0ntcnt ,1rea~ tlut must be cm·.:red, minimum hours th.a must be :,pent by .1II stmknts in dinil.'.,11 setting~, .1nd competencies or ,killi. th,lt .111 ~tu dent~ mu:,t posses~ .lt the completion of the nursing progr.1m ( Bul.md & Finke, 2012).

Simik1r to the imp.1et on M,1t,: bo;1rd aircria, ch,: T~·ler model ha~ hc;n-il~, inllu- c1Ked the fr.imework for a.ccrcditation by the Natiun.11 League for Nur~ing. (NL}.:). Through the al.'.crcditation process, the NLN ha~ had ,1 gre,1t imptKt 011 the den:lop- ment, implcmentatil)n, and c,·,1lu,nion of undergr,1du.nc nursing curril.'.ul.1 l Bol,rnd & Finke.2012 ). The fiN :--:LN .1e.:cr.:dit.1tion ,isit~ \\',:re in 19.W. and soon ~LN accred- itation n:quircmcnt~ bcc.1mc the ~t.rnd,1rd ti.Jr m1rsing education ( Lk,·is, 1989a; En·in. 20151. Beginning in 1972, the NLN criteria for b,Khdor·~ (bachdor of~cience in mming I BS}.; 11 prugr,1m~ included a critL·rion requiring tlut the curriculum be ba~ed 011 ,l cm1ccptu.1I fr.1me\\'ork that \Y,lS .:tm~istent \\'ith the sured philosophy, purpose~ • • rnd objecti\'cs oftbc progr.im (Kcllcy. 1975; NLN, 1972; \Vu, 1979 ). Like,,·ise, in the l 97(h, .iccrcdit.ition requiremenb for associ.uc degree in nursing f :\.D:--:) pro· gr.um required rhat rhc "conc.:ptu.il fr,1111c\\'ork of the prngr.1111 of lc.uning is de.uly ~rated .rnd implcm<:·nted" (NLN, 1977, p. 14).

~le leis ( 2012) ubscr\'cd th.u the recognition of rhc potential of nur~ing thcori..-~ to b1.: u~..-d a~ guiddinc~ for the c,mceptu.11 framework~ of nursing curricul.1 .md pro- grams in the 1960s .md 1970s coincided ,,·ith the development of mu~t of the nur-,ing thcoric~. indeed, nur~ing cduc,ltion promot.:d theory deYclopment in the seJrch for ,1 coherent pr.:sentacion of nur~ing to guide .rnd ~rructure cu1-ricul.1.

O\'cr the cnwing YL'Jrs, accredit.1tion ..:riteri.1 d1,111gcd somewhat. During thi~ time, "th.: requircm,:m~ for J conceptual frame\\tirk \\'ere a major ~ource of .;on- fusion .rnd concern among nur~e educator~" (Tanner, 1989, p. 8). !kc.ms..: of thi~ confusion, guidelines \\'ere changed, .rnd since the mid- l 98(h, they ha\'C been morl' flexible. :\lmt recently, the Accredit,nion Commission for Educ:i.tion in Nursing\ (ACEN) .Kcredit,1tion st.md.irds, for L'X,11nple, ~tate th,lt the curriculum must "in- corporate established profi:~sional stand,1rds, guideline~ .md competencies ... de.uly .1rticulatc student learning outcomes and progr.1m outcome.~ consistent with con - remporarv practice" ( ACEN, 20 I 7, p. 4 ). Thm, .1lthough not explicit!~· requiring .1 defined conceptu.11 fr.1me\\'ork, ,omc type of specific organizational 1-traccg,· mmt be used ro srrucrurc the progr.un.

Sim:e the mid- l 990s, tho: AAC::--J's Commission on Collcgi.uc Nursing Educ.1rion (CCNE) ha~ also been ;ic.:reJiting lxKc.11.lureatc ,rnd m.1ster\ nursing programs. In its accreditation stand.1rd~. like th,: :\.CEN, the CC~E doc~ not spccifr ,rn org.1ni1ing framework per ~c. R.i.thcr, the need for a curriculu frame\\'ork i~ implied a~ St.ind.ird I II states that the "currirnlum i~ ... logically i.tructured to ,Khievc expected indi,0id- u,1I ,md ,1ggreg;,nc student outcome~" (CCNE, 2013, St.md:i.rd III-C). Sec Link to Pr.1ctict: 22-1.

Conceptual/Organizational Frameworks for Nursing Curricula :\ \\'ell-dc\'dopcd ,rnd .1rricul,m:d rheorctic.11 or org.111iz,1tion.1l fr.11ne\\'ork gi\'e~ .1 nursing progr.1m the pcrspecti\'c that sh,1pcs the content .rnd the methods rhar guide srndenti. • learning; evenrnally, the content and methods prl:'senn.:d \\'ill h.ive ,rn impact on nursing pra(ti(e ( lwasi\\· & lioldenbcrg. 2015; Keating. 2015.i). A rheorctic,11 b,1~is pro,·id,:s the foundation rlut help~ nursing srudcnts define rheir protessional

Chapter 22 Application of Theory in Nursing Educotion 505

Link to Practice 22- l Application of Theoretical Information for Nursing Educators Lindo, the nurse from the opening cose study, was surprised ot the orgonizotionol struc- ture of nursing educotion os she studied the elements of teaching and of curriculum. She perused the boccoloureote essentials of the CCNE IAACN, 2008) to learn more about requirements for BSN education. As the nursing program she wos attending was preporing for accreditation, she asked to be ollowed to attend faculty meetings to gain more insight into the process. The choir of the committee welcomed Lindo to the ac- creditation preparation meetings, ond her attendance formed on informative learning experience regarding curriculum design and instructional strategies.

Access the CCNE website at http://www.oocn.nche.edu/educotion-resources /essential-series to learn more.

philosophic~ .rnd ,·Jluc~. It idenritie~ :mJ describes c~~cmi.,I co1Kcpr~ Jnd signitii:.1nt probkm~ .md ~ug.gcst~ Jpprn;1chcs to ,rructurc .rnd methods thJt the ~rudent may use in continuing to de,·clop their knowledge . Addirion.tll\', the: rhc:oretic1I fr.unework or model for the nur~ing progr.1111 c.m influc111:e the: mc.111~ by whkh 111.ucri.,I i!> pre· ~c1m:J .md the: mcthod~ by which lc.i.rning i~ c:valu,lted. Barnum ( l 998 ) wrote: th.1t rheorcric.i.l principle~ dr.1wn from .1 number of ,ourcc~ din.:ctl~· .i.fti:ct ., curriculum whether faculty mc:mbcr, recogniz.: it or not. Indeed, .1 nursing. curriculum conveys;\ theory ( or thcoric~ ) of nursing by ,·irtue of the content sclc.:dc.:d .

. mentioned prc.:,·iow,l~, the conceptual or org.mizJtionJl frJmework of .1 nurs- ing progr.un should be an outgro\\"th of the.: philmophy of thl· faculty, which t~-pic;.ill~· rdkct:o, the.: farnlty's philmophic.il bdict~ .ibout the metapar.1digm concept~ I Keating, 2015b; Sulli,-.m, 2016 ). The.: intc.:rrd.ninnship of thc.:~c concept:-, is the.: b.i.sic organi- .l,Uion.11 fr.une\\"ork of the.: curriculum, .111d as the.: concept1-o .ire further ,.kfincd within the fr.1mcwork, the.: curriculum becomes cst.1blish,·d. Addition.i.l concc.:ph .md t hc.:oric.:s s,:kctc.:d to comprise the n,ncepru.11 fr.,mc.:work ,ll'l'. likewis.: ukc:n from the philosophy ( Sulli,·an, 2016 l.

According. to Bevis ( l 989.1 ), ,\ curriculum concc.:ptu.,I framc.:work is ,lll "intcr- rd.icc.:d s~·stcm of prc.:misc.:s th,H pro,·ides guiddines or ground rule.:~ for nuking. all curricular dc.:cisions- objecti\'C~, content, implementation, .md c,·aluation" ( p. 26 ). The: conceptual fr.1111ework. may be referred to .1s the curriculum framework., the.: fr.,mc\\ ork for curriculum Jc,·dopmc.:nt, the conccptu.1! s~·stl·m, the curriculum the- ory, a theory of educ.1tion, or the: thc.:orc.:tk.,I framework, hut rc.:g:irdks~ of the name, it i~ the concc.:prualiz;ition .rnd .1rticul.1tion ofroncepts, fac.:ts, propositions, postul..1tc:s, thcoric:~, and ,·.i.riabk~ rckv.mr to the ~pccitic mirsing progr.,m.

Purposes of the Conceptuol Framework The concc.:pru..11 or org.miz.ttion.i.1 fr.1mework for ,1 curriculum :..1.:r,·e~ sen:rJI purpo~c.:s. Fir~c, it Jllo\\"s faculty to derc:nninc.: \\'hJt knowledge is important tn nursing ( i.e ., the concepts. principles, ,kill~ • ..ind thcoric~ to he co,·ered) Jlld how that knowl- edge ~hould b.: dd1ncd, c,negorizcd, and linkc.:d \\'ith other knowledge.:. It .ibo helps expl.1in ho\\ rhe~e ide.,~ or concept~ .1ppl~· ro nursing prJcticc. Second, the concc.:ptual

506 Unit IV Application of Theory in Nursing

fr.1mc,,·ork facilitate~ the sequencing .rnd prioritizing of knowledge in .1 way that is logical and intanally consistent. Tims, organizing fr.1111t·\\·orks prm·idc farnlty with a blueprint for construction of .1 ..:ohesi,·e currinilum to gi,-c ~tudents the cs~enti.11 lcJrning t'xpcricnces \\'hich will allo\\' thl'm to a..:hic\'c thc desired edu..:ation.11 out· .:omcs (Sullivan, 2016).

Designing a Curriculum Conceptual Framework Sulli\'an ( 2016) stated that there.: .,re two appro.1d1i:s to determining or dcn:loping an org.111i2Jtion.1l frame,,·ork for J rrnr~ing .:urrintlum. Faculty members m.1y choose a singk, specific nun,ing theory or model nn \\'hich to build the fr~1me\\'nrk, or the~· m.1y choose a more eclectic approach, selecting concept~ from multiple theories or mod- ds. She c.:xpl,1ined that use of a single rheorv to de\'c.:lop the n,m:eptu,11 framt·work help~ by pn"·iding a ~inglc im.1gt· \\'ith ,t defined ,·oc1bubry that is sh.ued by both the learner and the tca..:her. Newman ( 2008) Jgreed ;rnd \\TOtt· that using nursing models a~ the franK\\'ork for b.K..:abun:ate nursing edu..:ation would assist with identiti.:.ttion of tht· e~~t·nti;1) knowledge of tht· discipline and strrngthcn the purpmdi.rlness of nursing knowkdge in t·du(,ltion and pra(tice. \.Yhen a singk tht·ury i~ used as the fr.1mework, the faculty \\'ill Jdopt .rnd pcrl1.1ps .1d.1pt the theory and me its dctinitions and rdation~hips to structurt· .md organize content.

St·vcr.11 .1rtidt·, in the nursing litcraturt· de~cribt· thi: use of nursing theorit·~ .is the b.bis for rhc curriculum frJn1t·work of mrrsing prngr.1ms. In one example, Berbigli.1 ( 2011) pro\'ided a detailed expbnation of how Orem 's St·lf-C.1re Dt·fi.:it Theory (SCDT) can ht· mt·d as the ..:onceprual fran1t·,,·ork in BSN program~ . .-\lso fornsing on Orem 's SCDT, St·..:rcst ( 2008) tkscribed the process of tool dc,·dopment in .m Orcm-ba~ed ..:urri..:ulum and th\.'. rok of faculty in bringing a cmrin1lum revi~ion w fruition. Beckman, Boxley-Harges, .md K.1~kd ( 2012 ) disrnssed the processe~ u~t·d by fanrlty .tt tht·ir mir~ing program as their progr.1m tr.msirioned from an associated dq;ree prow.un to .1 BSN program using the Neuman Systems Model .t~ the curric- ul.lr frame\\'ork.

To .woid being constr.1incd by a single nursing theory or model, mnsr faculty choose an cdecti( ,tpproach th.tt combine~ many theories .md (0JKepb in frame- \\'ork den~lopment ( Kc.ning, 2015h; Sulli,·.111, 2016). Ofren, two or three organizing theme~ .1re med to build .1 curri..:ulum g1id. Thest· themes can bt· nriablcs, such as lite pluses, body systems, .md the nursing pro..:css.

If the eclectic approJ..:h i!> taken, a combin~ttion of many theories, concepts, or pr<Kcsse~ is used, .md borrmn·d .:01Kept~ mu~t lx· ~pecificall~· ddint"d for tht· pro- gram. Relationships between and among the ..:oncept~ must also be explained. On tht· other hJnd, .111 adYant.1ge ro .m cxkctic approach is the abilitY to incorporate .:oncepts .md tkfinitiom th.1t bt·~t tit the faculty's beliefs and ,·alues ( Sulli,·an, 2016 ).

Scn·r.11 year~ .1go, ,\kEwt·n .111d Brown (2002) compk-t~·d a brge-scJle, n.ttion· wide study that ex.1111ined the (urricul.u fr.1111e\\·orb of BSN, ADN, and diploma nursing program~. The findings illu~trated trends .lt th.it tinw in structuring the con· ceptual frameworks of nursing curricula. In general, tht" nursing process \\'as the most comn1<ml~, w,cd .:ompnnent of com:eptuJ) frame\\'ork~ for nursing curricula, being med by 5:i% of .1ll programs. Simpk-to·i:ompkx organiz.1tion ( 37% of .1ll programs), a hiopsychosoci.11 model {36% of .111 programs), .md nursing theorist~ (33% of Jll progr,1111~) were the other most frequently reported ..:ompont'nts. Of those identi· fying a nur~ing theory .l!, part of the i:onccptual framework, tht· most commonly reported nu~ing theori~ts Wt'.rc Orem, Roy, \V.it~on, Neum.rn, .111d Benner. Thl'. most comm011ly used non-nursing theories reported ,,·t·rc systems theory, Maslow·~ .1nd Erickson's theories, Jnd adaptation.

Chapter 22 Application of Theory in Nursing Education 507

Components of the Curricular Conceptual Framework The rwo major ,m:as to bl· .,ddressed during development of a currkulum fr.unework .1re ,1!> follows: ( l) \VhJt conl"ept~ will be l·overc-d? \2.l \\'h,lt \\·ill be the structun.:, 1mkring, or sequencing. for introdtKing the- l"onceph and ddineating the rel.nionships bl·twe.:n .111d .unung thl.'111?

Curriculum Concepts. Onl'l' .1 cOJKl'ptuJI framework for a nursing prog.r.1111 i~ agreed on, the- t,1-.k i, to idc-nti~· the- major cll'ml·nts or (onc,:pts that \\'ill appe.1r and reappl·ar ,H "thread.," .lt each len·I of the curriculum .rnJ thm prm·idt.> ,\ lu.,i~ for the organiza- tion .md .,equencing of contl'nt. ,\lost undergrnduate nursing curH:eptull framt·\,-ork~ minimally deloaibe the conc<'.'pts ofhe:ilth, person, enviromnent, .md m1r~ing.. Other concepts, such .,, c.1ring, selt~c.m.·, growth .md ,.kn-lopment, nursing procl'sl>, .rnd .1dapt.1tion, m.1y bt· .1ddl'd to expand or darit\ the fra1111:\,·ork. E.1ch of thl' Cl'ntral concepts .,houlJ be- Jdirn:d, .mJ the linkagl'., hetwn·n and among tl1l· concept:, should he l'Xplainl'd to unifr or intnn:!Jtc: the Lktails.

The- l"ono:ptual fr:imcwork nuy thcn u,..: .1dditiorul com,truct, or Je,·io:s to hdp ~tn1cture or organizt• thi: m.m:rial. It nuy u,l. dewlopml·nt.11 st.1gc, acute/chronic concept~, h1.:,1lth/ilhw~<. continuum, !>l'tting\, or thl' nur~ing procc:ss .t~ thl' d1id' orgJniler. In .1ddition, "proCl'S!, thn·aJ:," or them<.', Mc usu.1lly pre,t'nt throughout thl· curriculum. Tlw~e might indudr thl· nur~ing procc-~s. probkm solving, interpc:r- sonal rd.niomhips, .:ommunication, rl'Sl.',uch, change .. md te,Khing. EJch of thc:sl.' construct., or de\·ic.:es should .1lso be ddined ,1!1d <.'Xpl.1i1K·d.

Curriculum Structure or Sequencing. The rnrriculum b de\igrn.:d to providl· J. -.equence of le.uning l'xperienccs that will en.1bk ~rudent~ to achic\'e lk~ir('d l'ducational our- corm.·,. Content nuy Ix structu!'l'd or organized b.1~ed on ,ud1 vari.1bk~ .,~ location (e.g., hospir.11, .:lini.:~. commLmity), dnl'lopml'nta.l ~rage (e.g., infanr, child, .1dokscenr, adult, oldcr adult), or physiologi.: sy~tem~ ( c .g., rmrsculo.,kekr.tl, ga~troimc~tinal. cardio\'.isrn- lJr, rcproducti\'e). FJctnr~ robe considaed in seqlll'tKing the l'urriculum indmk .:onsid- L'r ation of the relationship~ Jmon!:!, thl· conccpt!, Jlld the Sl·querKe, in which tht· contl.'nt i.hould be ord1.Tl'd ~o th.lt the orgJniJ:ation .,upport\ till' sdc:crnl rdation!,hips. The con- ceptu.tl propl'rtics (attriburl's) of the concept~ to be le,irnl'd, .mJ the ~equl·nce in whid1 thl' coment is orden.:d, ~hould l~ log;ic.1l1y consist..:m. Tahk 22-l gi,·cs ex.1mpks of how sl'qul.'rKing c.m be used ro org.1nizl' .:oltrSl'S b.1scd on se,·er,11 par.1meter., (i.c:., met.1p.11-.1- dig;m concepts •• mributl's of the 1x•r.;i,n, ~ubconcepts, al-tivities, and complexity).

In mo~t progr.1111~, Sl'qlwncing; mo\·e., from con.:i:pts th.n arc n:bti,·dy ,imple to concept!- that .,re morl.' compkx or from \\'dines~ to progrc-ssi,·d~· seriom illnl'~l . ., ( Kl'ating, 20 I Sb). It lus been notl.'d th.tt both of these org.milational strategies c.m be probkmaric bl'c,rnse the lodt~~·\·idnn 11L"l'1.h of the ill dicnrt s J mJ,· be eJsil'r for tht nm·iL·e nur,,._. ro rL·cogniz..: .md lllllkr,t.md than the mon: .,ub1k hc:.1lrh nee~h of the wdl di1:nt( s l ( Scales, I 98S ).

Patterns of Curricular Conceptual Frameworks Th('re arl' two common p,1ttems of curriculum organization in nursing programs. Prob- Jbl~· thl' n1llrl' common on<.' is that of bloch11~r,cour.,e content. \Vh..:n courSl'S an: blocked, content is gen<.'rall~- struc·rured .,round ,1 p.1rtin1l.u dinic.11 spl·ci.ilty arl·a, dil'nt popub- tion, or body ~ystl'lll~. In this org;.mizational ~hi:mc, l'0l\tl'nt c.m bl.' organized Jccon1- ing to spl·rific practice sl.'tting., (t'.g., medic:il-surgicJI nursing, mental health nur~ing;, critical <.',lrl' nursing), de\·clopmental stages ( birth, infancy, chili.ihoo<l, Jdulthond, nlder adultt, or bod~- syMetm, (e.g., re.,pirJtory sysrem, circulatory .,ystem, dig;,...,ri,·c syst1.·rn 1. Thi~ .1ppro,Kh produce!, J curriculum that i, highly ~rrucmn:d (_Sulli,·an, 2016 J.

508 Unit IV Application of Theory in Nursing

Table 22-1 Methods for Sequencing Used in Nursing Curricula

Basis of Sequencing Beginning Level Intermediate Levels Final Level

Sequencing based Introduction to Focus on relationship between Focus on on metaporadigm the concepts ond person(s) and nursing; move interrelationship of concepts discussion that there ore toward focus on interrelationships oil concepts (persons,

interrelationships of person(s), nursing, ond health nursing, health, environment!

Sequencing based Concept of personhood Focus on individual; move to Forns on community on the attributes of established (individual, focus on family ond groups person(sl family, community!

Sequencing based Person (individual, family, Focus on relationship of individual Focus on relationship on relationships of community) identified; and the nursing gool of health of community ond the concepts nursing focused on restoration; environment is con- nursing goal of health

restoration, maintenance, trolled. M~ve to focus on nursing promotion; environ- or promotion; health on a of family ond/or groups ond ment is open ond less continuum; environment the goal of health maintenance; confined. is controlled environment is less controlled.

Sequencing based Student is on observer. Student is on observer-participant. Student is a participant- on activities practitioner.

Sequencing based Examines health care Examines health care environ- Examines health core environments with on complexity environments with few ments with many variables

variables complex variables

Source: Scoles ( 1985).

Su Iii\ :rn ( 20 l ()) nplairn:d th.u blOl:king h.,~ ~ti1111: .tlh,mtage~ bn:,1u~e it facilit,ltcs couN.: ;lssignmems Jnd compkments faculcy cxpnti~c. Also, in ,1 blocked course 1..ksign, it is e.i~y to tr.ice pl,1eemem of content within the curriculum. Howen:r, therL· ,m: ,ome concc.:rm. Blocking of content otren causes th.: content to bci.:omc isol,ucd from pre\'ious or following courses. This mJ~' impede the student\ .1bility to imcg;rJte knowledge and w tr.msfl'.r concepts, inform.nion, ,rnd expertise ,Kross c, nir~cs. :\nocher concern is th,H each .1r.:.1 is sdt~conc.1ined .rnd b.1~cd 011 ,1 Jitfrn:nc set of premisl'S hec.1use e,·ery 111,1jor block of~rudy is d.:ri\'cd from ,1 ditkrem theoretic.11 b.1se. ror l'Xamplc, BJrnum ( 1998, explained tl1Jt fund.11110:ntJb ofmm,ing focuses on skills, mcdic.tl-surgicJI nursing focusl"s on bod\' systems, ob~teuics is a lik eYcnt-b,1sed specialty, psyd1iat1ic nursing is b.1.~cd on cliL·nt bch,l\'ior .• md publi.: he.11th nursing is b.1scd on principles ofcpidemiolog\·•

The ~econd ct1rriculu111 p,1ttcrn i~ th.It of integrating or tbrmtfi,i._rr course con · tent. lnr.:gr.1ting cour~e comem is ,1 more.: concc.:ptual .1pproach to curriculum design. In the integrated curriculum, faculcy members identifr concepts considc.:rcd core eo nursing practice and then integrate or tl1re.1d tlll'M.' concepts throughout the cur· riculum. A nur~ing theory, for ex;,1mplc, ma\· be uscd co define core .:<mcepts ,Kro~s che progr.1111. Conccpcs that .1re frequently imeg;r;,1ted include life span de,·clopmcnt, nutrition, ,md pharnucolugy ( Sulli\·an, 2016 1.

Current Issues in Curriculum Development There ha\'e be.:n \c.:,·eral recent shifts in nursing curricul.l. firsc, innc.:Jsingly, community- based .rnd populJtion -focused components ,lrl' b.:ing .1ddcd to bc1!,ic curricul.1. Thi~ h;,1~ been cn.:ourJgcd by d1Jnges in the he.11th cm: ddi\'err sy~rem rl1.1t has mm·cd much

Box 22-2

Chapter 22 Application of Theory in Nursing Education

Concepts and Content Areas to Enhance in Nursing Education

Geriatrics/ gerontology Patient-centered core Evidence-based practice Cultural diversity and health disparities Spiritual core Technology jinfarmatics, electronic medical records, telehealth} Globalization of health problems (threat of spread of diseases) Alternative or complementary therapies Genetics ond genomics Palliative care/end-of-life core Population health Health core reform and reimbursement Health policy ond regulation issues Safety/ quality Leadership Ethics

509

of p.1ticnt c,1re out of the acLJtL' ,\lre hospitJI. With that shift, thL·rc hJs bcen a growing: rcnsion between currini!J th.n ti,cu~ on tcdmolo!,,-Y and p,lthoph,·\iolo!,'Y and thosc that focus on a more hum;mistic, holistic concept of nursing. Other rcccnt d1ange~ in nursing education involve less focu~ bcing given to skills and t;1sks, with ,l ..:om:spond- ing increJscd focus on the integration of content and probkm-solYing ~trJtegics .md con..:cpt-bascd nirricul.l (Cmnon & Boswdl, 2012; Dun..:.m & Sdrnlz, 2015; HJrdin & R.ich.1rd~o11, 2012 ).

~ursing cducamr~ n::cognize th.1t the content, concept~, principles, and thL·o1ic~ taught in nursing program~ should bc rcgula.rly upd:.m:d. For ex,rn1pk, thcrc ha~ bcen attention gin~n w strcngthening nursing curricula., parrkuiJrl~· in the .1rc.1~ of spirinul care (Burkhart & Schmidt, 2012; T.1ylor, Testcnm.n, & H.ut, 201-1-), sat~ty Jnd qu.11- ity (Bednash, Croncm,·ctt, & Dol,rn~ky, 2013; 1\lonsi,·;1i~ & Robimon, 2016; Pauly- O'Neill, Cooper, & Prinn, 2016; Rm, & Bru .. krk, 2016 /, genetic~ ( Farer, 2014-; Gic1relli & Rcitl: 2012; Jenkins & Calzone, 201-! ), gerontology ( Gray-Miceli ct al., 20 I-!; SkibJ, 2012 ), informari..:s ( Choi & Dc M.1rtinis, 2013; Weincr, Trangenstcin, Gordon, & i\kNcw, 2016), .md cnd-oflifr carc/palli.1ti,·c ..:arc (AACN, 2016; Jo~ephsen & 1\l.1rrz, 20 I-!). A numba of ar..-as in which cnh.111.::cd comcm in nursing programs should be ad- drcs~ed to meet current and futurc he.11th c.1re needs h,wc been idcncitied in thc nur~ing literature ( Lewis, 2012; Stoko\\·~ki, 2011 ). Box 22-2 summariLc~ the~c.

Theoretical Issues in Nursing Instruction To .1ecommod.1tc changing student protilcs and address the necd~ of ,tudent~ from diffcrcnt generations ( e.g., baby boomers, generation X, millennial), ~tudcnt~ from .1 Yariery of n!ltur.11 b.1ckground~, ,tuden~ with famil~· re~pomibilities, .md ~tudcnt~ from rcmotc or rural area~, nursing educators h,we obsen·ed th.1t ..:hang..-s or mod- ifications in methods of instruction .1re warranted. To this end, new tcai:hing \trat- egics, b.1scd on ~ound educational theories and resear..:h, should be den:loped .111d pnimoted.

510 Unit IV Application of Theory in Nursing

\Vhat is t.rnght in nursing prngrams can be di\'idl"d into three c.ltcgories: ( 1) cogniri,·e Ct>mcnt, ( 2) psychomotor tasks, ,rnd ( 3) applicuion of content .1.nd skills in nursing practice. Cogniti,·c cnment rdi:r~ to ,111 of the intiirmation the nurse k.1rns as background for ti.11Ktioning ( e.g., .111,ltom,._ physiology, pathology, pwd10lo6'Y, medical procedun:~, nursing ted1niques). Psychomotor tasks .lrl" thc acts or ski Il l> nurses perform ai:i:ording to a giwn rationak by ;:ipplying .1.i:i:epted techniques (e.g., administe1ing medic;:itions, ch:mging Jrcssings, inserting intra,·cnous lincs). Applica- tion ofrog.nitiYe knowkdge and skills inn>lws recognizing and interpreting phcnom- en.1 in the clinical setting ,rnd ,1d.1pting c.m: b.1~cd on the inrcrprct.1tion.

Tcad1ing str.ucgics ,llT different for each of the three .1re.u,. Cogniti\'c content is easily trJnsmitted through .1 variety of mean!>: le..:rurcs, discussions, progr.1.mmed karning, or rcading assignmcms .. -\cquisition of ..:ognitiw ..:on tent can be .1d1icvcd in thc .:ibscncc of skilkd tcai:hing if anothn sour<.:T of information (i.e., .1 t.:xtbook) i~ .1\',1iLlbk. Psyi:homotor skills require: 1.kmonstrJtion, return dcnmnstr,1tion \\'ith i:or- rectin: ti:edbai:k, and skill Jewlopment through pr,Ktii:c. Learning to .1pply cngniti,·c knowledge and p~ychomutor skills in pr,Ktii:e is the most complex k.uning t.1sk ,rnd t.1kcs rim..- JS kaming ai:i:umtil.nes from multiple dinic.11 expcricnccs in \',lril·d settings. Increasingly, simulation is b..-ing utilizcd to de,·dop and r..-nnc psychomotor skilk

The: following sections ex.1minl' t\\'o major issucs in nursing instruction. These .ire incorpor.1tion of multiple th..-ory-based stratq~ies in tl·.1i:hing .md the use uf tc:ch- nology in nursing cdui:.uion. Use of multipk tcxhing srr.m:gies is importJnt to c:nablc nursing srudc:11ts to .i.rt,1in i:ognitiw i:ont..-nr .md psydrnmotor skill~ and, most import.i.nrh-, cnablc thc:m to .1ppl~- these in dinical settings. Tcchnologii: insrrui:rion is indudcd bci:ause it i~ b..-coming ini:re.i.singly imporr.1m in nursing education, .111d the use of dist.ll1Cl' cduc.uion methods has bci:omc commonplacc in nursing edui:.nion, parricul.lrly in grad um.: progr.1ms ( Russell, 20 l :i ).

Theory·Based Teaching Strategies To best mei.:r th..- lc.uning needs of student.!, .H the beginning nfth.: 21st century, nul"'i- ing edui:ators .,re cncour,1gcd to movc beyond reliance on tJ"aditional tedrniques ofkc- ture .rnd n:ading .issignmems to incorporatc other re.1i:hing strategics that .m: based on sound theuretii:.11 principle~. Some theorctii:ally b.1sed strategics suggcstcd by Barnum ( l 99~ I .ire diaki:tic lcarning, problem-based karning, operation,11 instruaion, and lo- gistic teaching. Eai:h of thcse strategies is prcsemed in this s1.·i:tion, J!ong \\'ith cx.1111- pks from the nursing litaJturc sho\\'ing ho\\' they han: been applied in education.

Dialectic Learning Traditional di.ilcctic tc.1d1ing kads students to dc\'clop and expand tht'ir own tho ught~ on .1 gi,·en subj.:i:t, primarily through thc usc of well-constructed qu.:stions. Qu..:Mioning cJn lc.i.d to dcmonstration ofincon~ist..:ncies in, or contr,1di.::tions to, th..: student\ position. In di.1logue, tht' srud..:nt mo, c~ from ., 11.11-ro\\ i:onception of rhc subject m.lttlT to .1 bro.1der and more compr.:hcnsivo: und..:rstanding that encomp.1sses nwn: ,:,·ents and more i:ompkxiries. Dialngu.: ofrcn results in selfri.:\'cbtion hei:.mse the student i~ requir..:d to think through issue<; "·hik i:onsidering .mswcr~ to i:omplex questions (Barnum, 1998 ).

Application to Nursing. Diakctii: te.i.d1ing is used frequently in nursing cdtK.1tion. ror n.1mplc, it j,; i:ommonly used in clinical situation~ .md postdinical conferences. Di.1lccti( te.1ehing; has shown to be effo:cri,·c in upcbted 1.·x.1111plcs of dinic.11 post..:on- t~rences J.S desi:ribcd by Si:ha,m ,md Kuennen (2012) .md \"chic :111d Roy.ti (20101.

Chapter 22 Application of Theory in Nursing Ed ucation 511

ln other examples of tli.llcctic stran:gii:s, Brown .rnd Schmidt ( 2016 l explained h(m- a service-learning project used dialogue to develop critiG1I thinking in postcontcrcnccs, .md Kow·alski and Horner ( 2015 l reported on the effr.ctivenL'ss of discussions \\-hen using ,1 "flipp,d cb55room" appnnch r.1th<:r th.111 .1 lecture format.

Problem·Bosed Learning Strategies Problem -based learning ( PBL) involves the -use of predefined clinical sirnations and case studies to enhJnL'e or stimubtc students to acquirL' spccilic skills, knowkdge, and abilities ( PhiUips, 2016 '!. Si111ul.1ted dient5 m.1y be used, or tht' student might be giwn .1 n:a'I probkm in JI! .1crnal dinical c,15c; the objecti,·L' of l'Bl is to determine how to manage the p<:rson 's care.

l'BL allows the instructor to manipubte multiple v,1ri~1blcs to add increasingly complex Lssucs or .:in::umstancc.:s th.1,r must lx· considered in problem resolution. for hcginncr studL'nts, the teacher nu,· idcnti~· the problems but kt the students scck solu- tions. Or the tea.:her m.1y use the case ,15 .1 problem-seeking exercise, teaching stucknts how ro tind the import.mt fact-5 .1111ong the .m·;l\- of a\'ailable d.1r,1 ( B.mmm, 1998).

In .1ddition, PBL encourage~ self-direction, inteqxrsonal communication, Jnd use of information te.:hnology. Typically, .snulll groups of ~tudcnts work togcthcr in sdt:dircctcd tc.:-.ims; tht· rn~c !>tudies .:h.11lcngc them to impro\'C their critical think- ing c.1p.1bilities, learn selt:c,·aluation srr.m:gies, .md promote communic:uion among peers ( Bentley, 2004; Phillip~, 2016 ). Although it i~ ·.rn cffccti,·c lc.:arning stratc~ry, l'BL can be timc-imensi\'e to implement because it rc.:quirc5 faculty to de,·clop rcalistic scen.1rio~ that usuall~· focm on probkm~ encountered by .1 5ingle indi,·idual and/or family in J dungc.:abk clinical situJtiun (Bentley, 2004 ).

Application to Nursing. PBL techniques .1rc commonly used in nursing education. For -exam pk, Hodges and l\Llsscy (2015) explored the ctfrcts of PBL o n .m inter- profrssional course.: looking ·,1t thl· intcrdq1cndcncc of nun,cs .111d pharmacist~. The~· determined that the PBL .1cti,·itics .11lom:d the stude1ns the "opportunit~· to explore profrssion.11 interdependence \\'hilc ma5tcring fact-basL'd content" (Hodges & Ma~sey, 2015, p. 205). In ,mother exam pk, Athcmm I 2015) mcd PBL .lCti\'i ties in teaching mental health nursing students, concluding that PBL should be considered .1s .111

,1ltcrnati,·e to the usual didactic teaching processes. Finally, J\hrtyn, Terwijn, Kck, and Huijser (201 4') found that PBL-bascd learning activitic.~ cnh.rnccd b1c·ginning nursing st11dcm\ rc.1dincss for rritic.11 thinking.

Operational Teaching Stiralegies Operntional tL·adting strategics focus on presenting \'arious pcrspcctin:s regarding an .1gc:nt or issue. A s~·mposium th.n uses speakers \\'ith diffi:rcnt pcrspectiws on the same subject matter or a deb.He is ,lll cx.rn1pk. Othn operational stratcgics focm on pro,·iding diftcrent or ,uypic.11 .1Cti1·ities for the lc-Jrner. Using edu.:ational gamc:. or l'iewing nonmcdical ,·idem for illu5tration is considcrcd to be operational teaching acti,·itic.:s ( B.mrnm, 1998).

Application to Nursing. Many nurc~ing faculty use oper.1tio11.1l teaching techniques to make lcarning more interesting ·,rnd enjoyable ,md n, prol'idc.: .1 diffi:rent perspccti,·e on a particular topic ( Herrman, 2(H I; Robb, 2012 ). L1sc of g~1111es to enhance stu - dc:nts' decision making, critical thinking, .ind teamwork ,,-.1s de~crihed b\' StJ.Ilie\' Jnd ... ... . . L1timer ( 2011 ). In other ex~1mples, T homas ~rnd Schuessler ( 2016) used game~ and humor along \\'ith c.1se studies to improve nursing stud,.:nt o utcomes in a pharmacol- og~· course. Similarly, .1 group led b~· Day-Black, krrill, Konzdman, \VilliJms, and

512 Unit IV Application of Theory in Nursing

H.1rt l 20 l 5) used "serious games'" .1s oni: str.m:gy for teaching ~rudcnts in .m n nline community hi:,1l th nursing cour~c . l 1st' of moYies, films, ,md tcle,·ision ,lS .1 method to '-·ngage nursing !>tudent~ w.1~ desnibcd by sen:r.11 nursing edu,·;uor~ ( l\h:Allist.:r, 2015; Oh, D'-· G.1gnc, & K.rng, 2013; \Vibon, Bbk..·, T1~for, & Hannings, 2013 L

Logistic Teaching Strategies Logistic reaching. ,;tratcgies a rc b.1~ed on the umcept of master~· ofsequcmi,11 k.uning. Logisti<.: tc,1d1ing ted111i4uc~ generally di,·ide the m.:iterial to be k,1rned into k.m,ing scqrn:nce~. where ,Kquisition of one ~c:ction of the m.ltcrial is .1 nn:cs sary pn:n:quisitc to acqui~ition of .mother co mpnnc:m. Logi~tic strJtcgics teach the srndc:nt cle.uly defined compo nent~ .md prm·idi: for n:infrm.:c1m:nt :md tc:sting of each cnmponi:nt as the program progresses. As ,cdio ns of the material .tre added .md rel.1ted to each other, knowledge .Kcumulates ( B.,rnum, l 998 ).

Fornutiw testing is ,1 logi~tic tc.1i:hing. strJtcg~· bo:caus.: .1 course is ..:oni:ei,·ed a<. consbting. of sep.1r.1te and definite unit, .md res[', .ire constructed to mc.1,url' .1tt.1in- 1rn:nt ofcad1 unit. Other strategic\ includi: use ofsdf-instruction.11 moduk~ and port· folim; the~i: .m: typi.:allv logistic in natun: bec.1Ltse they follow a pJtr..-rn of .,s~embling information that is built on pre,·iow,I~· cxpbined nuh:rial ( Phillip~, 20 l 6 ).

Application to Nursing. Logistic or sequential teaching is common in nursing cur- ricula .rnd h.1~ been eftccti,·i: bcc.m~e (()urses .1rc sequenced .md must be passed, ,rn'-i objccri,·cs or outconh.:~ met, bcti.in: student~ can progn:ss to the next course or lc\'d . Examples from recent nursing litcr,lture include J work by W.1~sd: Riz.1, /\1Jciag;, Worden, and Delancy ( 2012 ), \\·hich dc~i:ribed ,1 mechanism in \\"hich graduate: stu - dt'ms \\'cri: rc'-Juiri:d to m.1i11tain Jnd periodic.11lv ,ubmit electronic portfolim to doc- ument .1c.1,kmic progrc~5. Al~o dcscribing h(m portfolios can be med ctkcti\'cl~· a~ summ.Hi\\: .1ssessmenr for nursing student progression ,n:rc Hill l 2012 ) .md Smith Jnd /\kDon.1ld (20 l I. l'~e of module~ to promote learning \\"a~ de~cribcd in ~c\'i:ra l sim.1tions. Ex.1111pk~ include ming J. modubr form.11 to tcJch ethic~ to un,krgr.1d- uat'-' BSN stu,knt, ( H~u & Hsieh, 2011 ), gradu,1te students .1.bout complcment.uy .md .1ltcrn.1ti,·e thcrJpies ( s,,·;111son et al., 2012 1, and di, Jster m.111ag:ement for public health nur~es ( Chiu, Poli,·ka, & Scanlc~', 2012 ).

Use of Technology in Nursing Education The me of tcchnology-b,1!,ed ,fotance k .1rning method!>, ~uch ,1!:, the Internet and imcracti,·e videoconferencing, has become \\·idespread in nursing progr.1111!:, . ln .1ddi- tio n , comp uter-assisted instruction, which h.1s been aYail.tblc ,ince the eJrl~· 1990s, i!:, becoming more sophisticJted and much more widely u~ed in nursing educ.ition.

T hn:e main types oftechnolob~'-bJ!:,Cd educJtional mcrhmh .ire a,·Jilablc to nursing edu.:,uor~. lnter.ictivc dist.rnce k.uning include~ the me of rwo-\Ll~' ,·ideo .rnd audio bro.1dc.1!>ts c,1rried c in:r telephone lines. Internet co urse!:, \\'ith inter.Ktiw ,·ideo dJss- ruoms now arc brn.1dc.1st from coll.:ge!> and uniwn,itii:~ to which student~ in \\'idcl~· dispersed geographic lo cation!:, can participat.:. Thi~ technology, c.11led sy11dmmow ddiPcry, requin:s th.u te,1d1er ,md <;tudcnt be ,1,·ail.lhlc to each oth..:r simultan,·ow.ly ( Fric!>th, 2016 I. :\no ther imeractivc distance learning technique uses \'irrual i.:hssron ms that .m: ,l\·,1ilablc to ~tudent~ who hJxe Internet c.mi.ers. Thcs~· inn: r.1i:ti\·c \"in u,11 class- room~ ,1rc ,l\'aibbk .lt all hours Yi.1 a st'rrcr. Finally, computcr-b.iscd virru,11 re,1lity !:,imubrions allo\,. stu~knt~ under the guidance of the nursing educator to rehears..: psychomotor intcn·i:ntions in realistic nursing ~itu.uion~ prio r to pl.lcing the pa tient into thi: learning. simation as \\'hat h appem in a practii:um (Cannon & Boswcll, 2012 ).

Chapter 22 Application of Theory in Nursing Education 513

f.uniliarity "·ith both synchronous ( i111111edi..1te or real-time an:ess) .md ,,syr1c:hro- nuus { dcl.1yed access) technology m,1k,:s it pos~ible to use multipl,: tc.:aching strategies. \'irtu.il cl.is~rooms m.i,· combin,: both s\'nchronous .md as,·nchronou~ t.:chnulog\'. .. . . .... Synchronous t,:drnology ( e.g., ,·ideoconfrrencing, chat rooms, ..1nd r,:al-ti1m.- onlim: cl,1ssroom~) allo\\'S studc.:nts to ha,·e rerso11..1l cum..1ct \\'ith the imtructor \\"ith immc.:di- .ue fredback, simil.1r to facc.:-to-facc instruction, .1lthough th,: depth llf the discussion m..1y ~utfrr. t\s~·n..:hronou~ tc.:drnology permits students to fit k..1rning into their bus~· lifrstylc\. As~·n..:hronou~ methmh ,111<..m ~tudent~ to ..111swc.:r in greater derth became th,:y ha,·,: time to cunsidt:r .111 ans\\·er.

Syn..:hmnom method~, ~u..:h J.~ ,·ideoconfrrencing, utter slighth· morL' tradi- tion.ii rL'(fagogy than stri..:t rcli..1n..:L' on IntL'rnct dcli\'cry, as the imtrnctor i~ ~ccn ;md hc,mj Jnd, through multiple media, ..:an presL'nr J bro.1d and di,·L'r\L' b:ture format. Deprnding on the depth .md diffkulty of the materials, students 1113~· respond less frequently in the \'idL'o cl..1s~room tlun un a ch.u facility in the ,·irtu,11 dassroom. Use of both syn.:hronow, ..1nd ..1synchrunous methods support~ adult k.1rning mon: effccti,·cly tl1.1n any single method alone.

Virtual reality simulation is ,m innovation in dinical skills L'ducation and often L'mploys ust· of high-fidelity hum;rn p.ltient simulators. Sorm· of these comrmerized mannequins produce motion and sounds th.u .11low realistic situations .1s studt·nts pr.KticL' assessing, planning, and .:.1rrying. out intavention~. Th,: faculty preprogram the simu!J.tor with clinical situatiom to ,lllmv students ro pr,Ktice skilb in,\ patient-safr emironmrnt {C..1nnon & Boswell, 2012; JdfriL's, S\\obod;.1, & Ak.intltk, 2016).

High-fidelity patient simubtion is thL' closest thing to \'irtu.1I reJliry current]~, being widclv med in nursing 1."duc.1tion. High-fiddity simulation typi..:alh· consists of ,1 mannequin ,rnd the app..1r..1n1s within, which is programmL'd and .1..:cesscd using a bptop, desktop, or h.rndhcld ..:omputcr. Sewral current models simulate patients of .111 .1ges prm·iding students \\'ith opporrunitiL's to ..1sscs~ heart, lung, .md huwd sound~ .md initiate inten·L'nrions to deal \\'ith multiple ~itu.uions ..111d patient rL'spome~ ( Bussard, 2016; Jeffries, 2012; kffries ,:t al., 2016).

Issues in Technology-Based Teaching SL'veral issues should be considered \\·hen .1ppl~·ing technologi,: inm>,·atiom in mming instruction. Instructors \\'ho u.,e dist.mce education by electroni.: mod.1litiL's should be famili.u \\ ith the technolob'Y at the u~er ln·cl ..1nd mu~r c..1rcfully dc\ign (ourse~ for Stll·

drnts inn>h-L'd in sdf-paced, independent ~tudy. Furthermore, faculty using dcctronic L'duc.1tional methods should lw famili.1r with principks of adult learning ( Knowles. 1980 l when constructing thL' curricul., .md th1..· course work ti.ir electronic deli\'ery.

Institutinn.,I issuL's indudc the prm·ision ofthL' rechnolot-'Y, software, ,md facilities for its us.: ( Thompson, 2016 ). F.1rnlty responsibilities include de~ign or modification of th.: curriculum ,rnd the cours.: contc::nt to ref!L'ct technology-ba~ed ddi\'ery. Other faculty ..:011..:.:rn~ ,1rc the t~-pc of media to be used, faculry-~tudcnt i1m.·rac.:tion, tech- nology man..1gcmcnt, studL'nt L'YJlu..1tion, and faculty and .:ourse evaluation ( C.rnnun & Roswell, 2012; Horsley & \Vamb:i.:h, 2015; Jeffries, 2012; 1.uhbcr,; & Rossnun, 2017; \Vod.1, Gnrcnke, Alt-Gchrn1.lll , & H.mscn, 2016 ).

DcbriL'ting is considered to be ,lll essential part of the clinical simulation le.un- ing process. During dL'bricfing, student~ and cducJtors can re,·ic\\· wh..1t went on in thL' simubtion, .md the educ.ltor can ..:orrecr an~· mi~sL'd information or give posi,- ti,·e tl'.edb,1ck to the ~n,dents (PaddL'n-Denmead, Sc..1tfati, Kerky, & Farsidc, 2016; P.ige-Cutrar.i & Turk, 2017 ).

Numerou~ rlatforrns ;tr,: availabk tu educators th.n permit multipk mL'thods of intL'rfa.:L' ba\\·el'n th,: teacher and studL'nt. Thest· progr.111H allow studL'nts to g.iin

514 Unit IV Application of Theory in Nursing

,K..:ess to rhe course m.m:rials on rheir o\\'n ~..:hcJuk .md to h,lh' r..:,11-rime npcri- en..:es with rhe instru..:tor, such ,h is found in a ..:hat fa..:ility ur un .1 syn..:hronow, ,md relephone-lu~ed format such ,h Skype. Som..: .1lso .11lm\· te~ring and provide securitY parameters rn ,mthorize only th1: tcad1cr .tnd swJent to have .1..:..:c~~ ro rhe sttKknt'~ n.~..:ords. E-nuib, blog~. Twitter ti:eJ~, \,·iki~, and so..:ial media form.it~ permit me~sagc~ bd\\"een instru..:tnr .md stud1:ms .md among stuJents or groups of student~ through password-prorccteJ m1:.ms. It i~ in..:umbcm to mention tlur any inform,ltion th.1t shou!J not be Jistributcd to the public ~hould nor bt: ~!urn! through rhe,e mt:dia.

To t.1ke .1J,·.1ntJ.ge of dectroni..: te,Khing methoJs, tl11: imtru..:tor mu~r be..:ome proti..:i~:nr in multiple met.hod~ of ..:rnwt:ying ..:onrent ,md should bc prcp.m:J to apply appropri,lt<: le,m1ing theoties. Tt:chnolog~ -based edu..:ation t:mbra..:cs ,1dult t:du..:ational prin..:ipb. ImkeJ, thi.: ..:onti.:nt is prt:!>l'.ntt:d in usdi.tl fiirm, the immediacy ofthc ~tuJi.:m\ need for knowlt:dgi.: is supportnl, .rnd thi.: studt:nt\ abilitv tu rely on pr1:,·im1s knuwl- t:dge bast: tu prm·idc a ti,und.1tio11 for hi~ or hi.:r qui.:,rioning .ue .11! prcsent in the typic,tl imer,Ktiw web-ba~ed d.,s~room. The u~t: , if multiple way~ uf presenting rhi.: 111,1te1i.1I in .1 ..:our~~· ..:onducted using intcractivi.: t~·clmology-b.1 cJ education/lcarnin1:t L·reati.:, the srimulu~ for learning .md expand~ tht: educ,ltor':, .1bilities in crnweying cou1,1: conti.:nt.

Although rhe re,\·;1rd~ of ti.:aching by dectronic method~ arc m.my, thcrc .ue .1lso i~sues of \\"hich faculty whc, ;1ri.: teaching on line Cllllr!,l'S !>hould be m.1de ,1\\·Jrt:. for example, distance mcthods sud, ,ls web-based ti.:aching may rcquiri.: mure time th.111 in-dass, fa..:e-m-fa..:e ~tr.ucgit:s ( AnJersrn & .-hery. 2008; 1'vk-\fooes, 20 l 6 ). The llL'C· e~sary time to spi.:nd on this a..:ti,·ity i!, be..:oming more recognizcJ but h,1~ still nor been adequately Jddres~i.:d by eJu..:ation.11 ,1dmini!,tr.1ton,. Pn:p,1r,1tion timi.: npand~ including the time ni.:<.:es.,.1ry to 11:arn nc,, de..:rronic tea..:hing mcrhod~. In~kcd, the time th.lt instru..:tors inYest in teaching online ..:,,tir,cs c.111 bi.: overwhelming w both no\'i..:i.:s .md cxpi.:rienccd educ.ltors.

The ,1Jvamagi.: ohH·b-h.1st:d insrru..:tiun is th.u communication ..:an b1: carrii.:d on all houri. of tht: day, 7 J.1y~ m:ekly, by web-b.1sed d,1ssroom. ,·irtu,11 ..:h.1t, dis..:ussion board~, e-mail, fax, and tdephonc (Mc,-\fooe~.2016 ). Although the educ.1tor becomi.:~ a faciliutnr of.1dult cduc.1tion and the !,trategic~ .ire organizi.:J to t.1ke aJ\·mt.1ge of the self directed, indt:pcnd..:nt nature of the karner~. the cducuur soun learn~ it is impor- tant to 111,mage time to ,1\uid bt:..:oming o,·crwhdmi.:d ( frie~th, 2016; J\ k-\fooi.:s, 2016 ). Educatori. who arc ..:onremp!Jting using \\"t:b-b,1!,nl teJching- learning str.ucgie~ should ..:onsult with seasoned facult:y mentors. They should be encouraged to t.1kc ad,·anr;1gi.: of their experience with the mi.:thoJ~ of deli,·ery for de..:tronic t:du..:ation, peruse thi.: liti.:raturc Jbout the i~~ue~ of tinw and re..:ognition, .rnd negmi.1re from .1 position of knowkdge to obtain the required timi.: and promi~e ufrecognition.

Application to Nursing .. -\!though ted111ology-b,1scd imtru..:tion in nursing is rdatiwly new, ,\11 increasing number of examples ha\·e appeared in the liter.nun: dt:scribing how te..:hnolob'}. is being u~ed in nursing t:duc.nion anJ ~fa..:ussing sucees~e~ .111d ks- sons kamt:d. lk..:ause ,imulation has be..:ome widely u~eJ, the literJturi.: is full of examples describing how it ..:.111 be ust:d in many aspe..:b of rwr~ing edu..:arion. for ex.rn1pk. Burb.1cl1, Bam.1s011, .md Thompson ( 201; J used a "Think .-\louJ" ~trat- egy with L,,1e.:c.1laureatt: nursing stuJent~ to ..:,1ptun." their clinic.1I reasoning .1s they took p,1rt in J dini..:.11 ~imulation. Their tindings suggesti.:d rhar simulation " ·,1~ ,111

i.:xcelknt " ·ay to ,1sses~ students' clini..:;11 reasoning J~ they performed skills in J sim- ulated clinical enYironment. In another example, Stri..:kl.rnd and ,\ l.ueh ( 201;; l u~t:d :111 experimental design to quanti~• the impact of simubtion on dida..:ti..: karnini,: ,rnd high ~takes 1:xaminarion mrtcoml'~. They founJ th.u exami1urion scort:~ of the ~tu- denrs who had participareJ in the simubtion wt:rc higher tlun of those who had nm.

Chapter 22 Application of Theory in Nursing Education 515

In .1 third cx.impk, D,1mc and Hocbckc 12016) dcwlopcd .m end-ofliti:-c.irc 5imul.Hion in \\ hid1 they mcasun:d pre- .1nd post- ... imul.nion .Htirudc'.', tim ,1rd c.1.n: of rhc dying nf sophomore nursing srudcnts. Thcy found th.1t '>tudcnt .ntitudc, to- " .ird c.1ring for d~·ing p.niem_., impro\'cd .1fo:r the ... imulation. Rus~.ud \ 2016 ), in l

(]llJ.!itJtin.· dc-,criptin: study, found th.it ,·id1:ot.1ped high-tiddiry _.,i1mil.1riom .1 ... sistcd ... rudcnr, in sclf.rdb:tion on their practkc. \'ideo-recordcd ,i111ul.1tiom henetim:d till' ~tudcnt<; in thcir dcn:loping dinical judgment.

Fi11.1lly, ~kPhcr.,on .md ,\ t.1el1on.1ld 1_2017) blended :-,imul.uion-ba.,ni le,1rning wirh intcrprcti\"C pe,.fagogy in ,1 le.1~-lcr.;hip ~·oursc .1nd found that ,rndents mo\'ed from merely knowing thcoric., ro more dfrl·tivcl~- .1pplying. kadcrship principle., in ,Kti<m.

Through thc_.,c rcs1.•.m:h ,nrdil'-" .md nuny others, it is 1.·\'i1.knt that m.my itcra- tiom .md combin.niom of int1:gr .itcd, participJtory simul.ited expcricncc_., :1rc dfrctiw te.iching str.m:gies in nursing. As the,c nluc.nion.11 expcriences .ire de\"Clnped, how- c,·cr, facuJry mu,t cmun: thJt thcy usl· .1pprop1;.uc karning thcoric, .rnd rccogni,ed .md e\·idcncc-bJ~ed tc.iching ,trJtegi1.'5.

Summary This ch.1ptcr h.l!, presented two m.1jor .1rca~ rde\'ant ro the me of theorctic principles .rnd modd~ in nursing cduc.nion: curri..:ulum design .ind imtruction. In the op..:ning ..:,l!,C .,cud~. Lind.1 .ind hcr d.,~\m,uc~ lc.irned th,u it i!. nccc~s.ir~· ro haw J sound, idcntincd thcoretic.11 b.1se to ,enc.,~ the framcwork for .1 mtr!,ing progr.rn,. They abo n:cngni,ed tl1.1r it is import.mt to !.deer multiple te.i..:hing str,ttegies to ddi,·er th1.· matai.1I in .1 m.111ncr th.u will be.,t ~upport student karning..

Likl·,,·ise, it is c.~senti.11 th.n .111 m1r,c nhi..:Jtor., be .m.uc of how rhcoreri.:.11 principle_., .ire u.,ed in cdw.:.1tiun. They !'>hould be .1hk to .irticularl· the concl:'ptu.il frame,\·ork of their progr.im ;ind rcl·ognizc how the fr.1m1.·work sh.1pe!, thl· prnw.1m. :--:ur,ing edt1Glt11r-, !>hould .il,o u,c multiple !.tr.1tqi;ie, .rnd tcdrni(JllCS ti1r imtrnction to cn.1blc !,tlldcnt, to develop their knowledge b.,~c .md to dewlop critil:,11 thinking .1bilitii:, .rnd prohkm-sol\'ing .,kills.

Firully, nursing .:du.:.itor!, ,hould re.:ognize th.n te..:hnology will pl.ty .m incrc,1~- ingly import.lilt rolc in nursing educ;ition .ind bc prep.ucd to in..:orpor:itt· te!,tCd di~- t.111..:e cdu..:.uion mcthoJ!, .mJ ,·irtu.1! rcaliry simul.ltion into imtruction.

Whether the fo..:m is continuing cdu..:ation of pr JCtidng nun,e~ or fund,\mt·nt.il cJuc.ition of ~tudcnt!> of thc discipline ,lt J.n~· k\'cl, modern tca..:hin~ .md k.1rni11g method~ m.1ke education.ii ctfort~ more .waibblc to J wide \'Jricty of indi,·iduals with a ,·ariety of edu..:,1tion:1I .rnd le.1r11ing need~, .n time~ \\'hen the student~ .ire mo~r .w.,il- .ibk, in widely 1.fotriburcd .1re,1., ofthc country. It is thereforc imperatin: th,lt nursing educ.nor~ understand rcle,·.mt prin..:ipks and theoric~ to .1ddre~~ rl11.·\e needs.

Key Points CurriculJ ,ire ..:reared by faculty to fulfill their ide,11, of nursing ed ucation .ind tu pru\'idc till' con1111uniry wirh eftcctin:, safo, wdl-cduc.ited mrr~cs. Curricul.1 .lrc bc~t organized .1round a guiding principk, be ir a nursing theory or .1 (ollc..:tion of nur,ing .111d shJred thcorics; the outcome is ro pro\"id~ the ,tudent~ with intellectual Jnd dinic.1I dcwlopmcnt .1, profrssion.1I nurses. Nursing pnigr.uns .ire c,·.ilu.ttcd .md ,Kcrcdited hy c,cver.11 bodie~, induding the ~tat~· bo.1rd, of nursing:, the A:\C~\ CC~ E, and the ACEN.

516 Unit IV Application of Theory in Nursing

Tca.:hing 1111:thod~ ~hould be theory- and n·idencc-bJ~cd to cnh.111.:e lc.uning. Inno\',ltions such .1~ critical thinking, PBL, and simul.uion .m.: part of many nursing curricula. Learning environments have c,·olved. Today, they include fully face-to-face, in-class learning; lwbrid models in \\'hi.:h some 1.:cmtcnt is presented via web-based meth- ods; and totalh- web-based i:oursc1- in whii:h .lll ofthc i:ontcnt i~ presented onlinc.

Learnin Activities

1. Following the example of Linda, the nurse from the opening case study, work with other students ta outline the curriculum for an undergraduate, prelicensure nursing program or o program to prepare advanced practice nurses. Start with development of a curricular framework and identification of the key concepts and content for the curriculum.

2. Select one of the courses in o nursing program and modify it to be delivered using some type of distance learning [e.g., Internet delivery, such as podcosling, or other innovative online methods]. How will presentation of the material be accomplished? How will students interact with each other and with the instructor? What activities will be added? What activities will be deleted?'

3. Search recent nursing literature for research on technology-based nursing edu- cation. Do these techniques appear to be as effective as traditional class work in ensuring that students achieve the goals or competencies of the nursing pro- gram? What ore the strengths and weaknesses of the research you hove found?

4. Discuss the use of patient simulators in clinical nursing staff education. Consider the cost and upkeep of the equipment for simulators and faculty training and education and the need for technicol support of the equipment.

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lk,b. f.. 0. i 197.11. ('urricufom lmildi,i .. 11 in 1111rsi11..11 . • { pmass. Sr. 1.oul\, MO: ~ln,hr.

Ikvi,. f. 0 1[9871. I Ii,tor~- of n1rm.-LLhLm dcn.·lopmcm. ln C11r- r,c11/111n n ·rnhtrum: .lfo11dnu fiJT' cbn,(ITl' i pp. 2; 40 I :--.:cw York. SY· ~.ttion.1! I c.u!lll: ti1r ~ur!r,,mlt. l'rc:c,,!-.

lk\ i,. E. ( l I l 9XlJ.1 • C11r1·io1/um "'t,mltimp w 111/Ntll/1." A f'rtl(t.CS \ 3rd cJ. L S .. ·" Y1 ,r"-. ~\". ~.mon.1l Lc..\lU.tu: fur Nur1,m~ Pre,,;,.

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llola11cl, I>. L.. & Finke. I .\I. 120121 Currkulum Jc,igl1\. 111 I) .\1 . Hillin~\ & I..-\. t-l.11'tc.\1o~ l Ed~. l, 1i:11c/Ji1tq m 111trsi11..11 . .--1 .. nmdc.fhr Jamhv 1-lrh ed., rP• 11 '1- l 37 I. St. l.uui,, MO: El,e\'1cr

Brown, J ~1.. & Sdunidt. S . :\. 120)61. ~cn·ii.:c-kJ.rning in un<..krgr.u.iuatc m1r-m¥ cdu..:-.1nun. \\'here i~ the rdk·(tion? J111m1nl ,i(l'r<(/r<.<i1111t1f :-.·11rsiltn, 32111, -111 53 dni·J0.11116/ j. prolilu,.,..2015.05 00 I

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Chapter 22 Application of Theory in Nursing Education 517

HurldMrt, L., & '\..:hn11Jt. \\'. 120121. ~k.t\llrin~ ctlCt.'tJ\..,:ttt.·~-. of .l ~pmtu.11 "·.uc pcdJ~uµ, m nur1in~ c:Jm.:Jtlon. }1111r11t1l uf 1'1·,~fi·.1.mmnl ·;,..,:11n11(n. 2<,•151, .l 1 :,-J2 I

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C,ulnon, S., & Bcr.-.wcll, C. 1,2012 ,. l:.'11id,-11rc·lmrtd U(ldiutn 111 w,r5- mn: -~ /i1u11d11tia11 for rd11rnt<1N. ~uJhur,·, ~L-'1- lonn & tlJrtktt l_;;Hll;;,r,. .

C'hiu. ~I.. Pnli1-k,. B. I., & Stanley. S. :\. It 12012 1 b·.1l11.uion uf • 1 di\..1,-ri:r-!-.urgc: l'rJmi11g. t(,r pulilk hc.dth 1nir,c, / 111/Jlu J frnlt/J :-.111-m1,n, 2~ l 1. 1.,n-142

Chn1, I.. & De !11Jrt1111,. l 1-.. 1.!0UJ. :S:u"lfl!! 111l11m1.ui.- ,rnn· pctcndc.:~: A-.~C\'ill)l'lll ,1r umkr~rJdu.itc J.llt..1 g:r.h.tU,lh: tlllt'frrilll~ "tudcm, J,mnm/,f('lininJ/ .\'r,nrn ... 11.121 lJ-)~ J. l'-170- 19-6

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l)J\' BI,,k. C., ~lcmll. I:.. 11 .• 1-:onLclm,n, L., \\'illi,m,. T. T.. & H.ln, !',;. 120151 li.11111tii:J.rnn1 . . -\n mnn\.1t1,c 1\;J~hin~-k .. nung ,tr .. h:g, ti.,r the 1,h!!,1tJI our~m~ -.1u<lcnt"- in J i.:ommunaty hc.llth nur,in[I: ,1111,-c. nl<' .~ ft.\'F Jr111r11,r/. 2t\i 4 1, '/(J-<14

l)uni.:,111. J.,:.., & \dutli. P. S. i 201 :\ ,. Tmp.,i.:t of .. ·h,Ul!-1,t: to .J .. ·on ,~pt ba.-.,J ha.:,al,urc~tc nuNni,; currkulum on ,tuJcnt ~nJ 1>roi,;n.m our,ontc•. /ortntlfl ,f~•:rmi11.11 EtliuntwN, .'i-41 J ~uppl. ,. ~Jt1-SlO.

hr\'111, ~. I\. 1. L2015 L Hi"itor~ uf ctur,,,Jng cJm:.nion in thr L·11itcd ~t.1tcs. In S. ll N:.1tmt?, f 1-.J ,. < ~,u-ritulum d,Ptlupnu,tt """ •·i•n.l· ,111rr,m in m,rsiu .. " t ]rJ cd . rP ;<~2). ~c\\ York. S\": Springer l'uhlishins.

l·.ltl"f. K. H ~201-¼ f. 1ntro.lu..,·in~ ~cnomi\.'tri to llo\kc b,,11.,:L:J!Jurc.ttt 1rnr-c;;111~ ,,uJcor .. Jm,rnnl ,,, ,\'11Nlt{q Ed,,,,,,;,,,,, .ilc'I Surrl.1. \I 111-.\llU.

l-r1c,1h. II ,\I. l 201 c, I. f,·.,d,in~ .11ul lcJrmnM- ,It J Ji,tJllCC 111 n. ~I. Hilling, & J. :\. H.,l,t .. ·.1d I Ed,. 1. Ta,dn11.n in um·smJr: ~i .. "mdt f'1r fiuttlt_-r 1 ~th c1.I .• pp ~-i2-3561. St. l.oui~. J\lO t-.l,t:'\·1cr

l,i.ul'lli. E., & Reiff. t..\ l20121. (.;"'•mmm.· liH .. ·r.1..:y ,rnd pr.h:tiL"<." ( .1II for ri.:,c,lrch on ,!,!l'ncric, m nur-.mi i:dui:.uhm .\'11n11ur ( 'lmtf, ur .\"orr/t Amall·a. -1"'"1 ... ,. 529-5-¼5.

<,r.l\ :O,,IJ,d;, r>., \\'11~ ,11. l. 0 .• 'i1.111k), I., Wunun. ll .• Shire ...... \utJcr, !I .• cc .li I .:!tl I~ Jmpn t\ lll~ the '-lu~h1\' of ~,:n.u ri ... nur-m~ .:.\(\:: f ndumlf I lllh.C nllC\ fn 111\ the gl·n.Hni.'. 1111r,m~ cdlll.'.JIHlll ,·nn-.c,rliuin f1111r11nl d/ PrtJti-»1,11111{ Xnnm,1. 3tA fJ • 4-1- -4:;='

H.irJtn. r K .• & Ra(:h,m.1•,,oo. -.. J. i20l2i 't..-..1d11nµ th\.· i.:onL·cpr 1..urnculJ: Theory Jnd method. }tmr11nl r~f .\'ttr,r,('1 F.,iurirtnm. .'il(Ji. 155- 15'1.

Hcrrm.m. J. \\'. , 20111 t.:...:cpm~ their .Jttc.·nt1011. lnno\.Jt1,·t· ,tr.JtC ~u:, for n11rr-1t1!,t t."llui.:111011 J,iur,u,J <1{C:,mr11111111,n l:.d1,mtm1t m Sm·mvr. ~2< IO 1 . .J.J9-l51>.

Hill. T. L 120121. Tiu· pc1rtti1lic, J\ ,1 ,umm.tt1\'c .l"-~·,,m .. ·111 t11r thl· nn~irl!?, ,tuJcnh ·r.-achitljl 11ud L-nr'1UI._IJ .. ,, .\'11rsi" ... "" 1 I). 140- 1.J;;

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Hor,,k,·. T. L.. & \\'.uttl>.1di. I,; 1 !O l 5 ,. Efli:.:t of nur.in~ 1:,,. ult} rrl,'.',('lh:1: uo ,1uJcnt-i.' Jlt'.\lt'~ , 11clf i.:nnfiJcn~-.·- .111J din 1~.1J 1x·rti1rm.ui ... c 1.furini J dinic~I -c;;unulJtum l''i:pt:m.·th..'C. C:li11iml S11111,/nt11m tit .\'11rsi11_t1, JI. +--10. doi·I0.1016/ 1.c,n, 101-UW 011

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Jeffrie,, I' R. \"obc1<IJ. S. M .• & :\kint,1<k. R. 1201111. TcJd11n!' Jnd kJrnmt1, u,ing ,imulltinn, In D . . \I Rillini, & J . .-\. I IJh,rc.1.d I F.J~. 1~ 'fr1ul11,~,r "' ,111rr111~1f: A ._1Jt1idt f'ur firo,lry I 5th ,,L rr- .,04-323 J. !\r. l.m11, •• \10. l:l,c\lcr.

Jenkin-.~ J • & C.,l1onc, J..:.. A. t 10 l -4 t. lii:n• •mio nunm~ facul~ dum1,1un ini1i.aun:. X11r1,· Eli1un1,,r. 3IJI I ,. 8-l .l .

Josephsen. J .. & .\!Jrtl, lo:. i10l41. b.:ult) Jnd ,rnJcnt pcr.:cpt1011, An end of life nur~ing cutrll"ulum 1iur,·c~. J,111r,u1/ ,!f'H,tsptu (""' 1'11/li111ii•,· .... -,,,.,i,111. /(1{8 I. 47-1-481.

l,;.cJtin),!.. '· n (201~.1 L Ovcn1t.·\\ nf nur.ill}! cJu~.Jrion: I 1i~1nn, ..:urnl'.ul11n, dl·, .. ·lopntc:nt prtk.c:,,c, .• ,mt rhi: role uf t~h::uln. In S. I\ Ki:~mnp. 1 l-t.L 1, c 'm•ruulm,, 1frl'd11pm,·1,r nw( lttnlwu11111 111 ,111n111p 1 ,lri.t cd . pp. 1---11. ~cw \'ork~ ~Y. '\pmig.t.·r Pllbh,hm~

K .. ·.Hm!!,. "I B ~101:i~. rhc ~omponcnl, ut th( \'.urni.:ulum In S. 1\. K1.·.um~ , h.t. J. c ·11rru11lllm dn•d,,pm, ur .1mi n·11!,u,rr"11 ,,, lllsr5· 11~,1 1 3rd i.:d . pp. l 85- 22M ), !\! .. ·,, Ynrl,.,, S\'. ~pnnttcr Publi,h111~.

~die:":~. J. ( 19-51 ·1'h1: i.:cmccptuJJ frJ111C\\t1rk 111 nur..mg c4.fu~J riun. lu C ·umc11/11m dr1•dopmr,r1. pnrt rl: C11rruu/1,n, rr1•1111m 111 b,uo,hJtowrtt 1wr1i,{lf rd1unri,m I pp. 15-201. ~I.'\\ York., :-=r. :-.:.u11,n,1I l.c,guc li,r :--:ur-inM- Pre,.,.

1-ntl\\b, ,\1. S. 1 l<J801. T11c """"'r,, prifl"tiu ,{ n1fo/1 rd11c11ndH. ,..,,.,,. prdn.lfO!fJ to n11dm_1ro_,i:.12nJ cJ. I Sc .. · \"c,n. :,,,:r: c,mt,n,lp:< Hnu>...,

J.,'..o\\'Jb,k1. .• & H~•rncr, ~t. 0. 12015 rn·p.1.rintt cduc.1tur" to u11plcmcm ftipJ,.,.'J d.1-.."n .. K~n\, .J11 Ji tcJchmg. ,u.1tc~. /01,r- 1111/ d{ ( .IJflftflll,,Ur f..tl11c/lt1n,, UI .\°UNUll1, ~>(I, 3.J(,-J.f7. ,lni:l!U11211/00220J2-l-201~0721 14 •

J.~\,h. 1'> . \'. ( 20121. fni.:urpnr.nin~ n.uion.1J prioritic:~ into the ,urri,ulum. /mm,n/ ,,[ l'r11/m1,ma/ ,,,.,,,.,_,,, ],~ 2 1. I 05-109.

l.uhhcr"\, ) .• & Rt~"i1n,1n. <. , 2r11-,. ",J.t11ir:11.tu,n .inJ ,df-.. ·c,nti.~kn~c \\·ith nuni1ng t.·l111it..".ll !.imul.1t11 in. ~t>\·1c1,: lc .. uncr,;;, mcdi11n1-th.lcl1t~. .md t.:ommunit\ ~nin~ .... Suru F.d1uort,m Iiufni·. 4S. 1-lO 1~1. ,lu1. IO IOlc,; (n,·,lt.2lJI<, Ill Olli

~1.itter. R l· 1 lY6.:? 1 /lrtpnr111,.11 111nn,rr1,m11/ ,1b1urr1•tJ. UcJmortt. lA: 1-c,m>n

.\lmyn. J., frrwijn, R.. 1-c~. M \' .. & Hrn1-cr, H. 201-11. Exrlonng th .. - rcl.n10n~hi("' bcf\\ ccn h.·.,~hinl{,, Jf'pru.i~hc, 10 kJnlm~ .JnJ ... nni.:.11 thmk.ing. u, J problem b,t"K:J kJrnm~ four11,.l.ttlon 1rnr,.111~ .._·,111r,,..: ~•11rst l:,durntum "/i1tl11v, 3~51, K2'J-X35 d111:lO. l(IICl /j.ncdt.21l l .H)Hl2.~ .

Z..lt.:AhMlll'\, I. c 20161. Tt.•,11.:hin1t JnJ k.Jrning m onlint knmnp. 1.•ml 111uni11c,. In D. M. llillin~, & J. :\ H.d,1cJJ I EJ,. ,, T(ndmu1111 1111rn11_11. A .11u1tl.- .f'o1·_tiu171,:, , ~th nl.. l'P· 357-.~83 1 ~t. l.,;u,,. ~10: ~]-.:via .

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1111dcrgr.hlt1Jtc.· m1r.,111~ (Urrkul1: Report of 1 n.nlotul sur\'c:y. J,,unml 11/ Xursm,11 J.1f1u1t11,111 • ./JI 11. 5-1-4.

.\1, l'hcr,on. l . & ~!Jd)un,IJ. l , 201- , llkn,lini,unul,11on·hJ-.:,I kaming .mll mt..:'l'n:tan,t.' ~c.lJ~o~ lt•r unJcr~r.1duJh.· lc:J.,lcr· -.lup ~um1x·ttni.:y ..tcH•lnpm .. ·m J,mn,11/ ,,, Xun11v1 l:tfttL'llfflJIJ, .,r, I 1. W - ~-l .1111:ICJ 3'1211 •(l[-iX.JX3.J .?Ol<•l219 Ill

~klci:i., A. r 1201.2 ·n,rt1rt1unl IUlrS.ill .. fl: l>t,•tfop11101I """ pr,tqros 15th c,l.1. l'hil.1<klph1.1. !'.\ · l.1p1>111,u11 ll1li1Jm, & \\'ilkin,

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~ludkr, t·. t2016J. .. ·n11..:4.: fc.irnmg: Dcn:lop111g \Jluc,, t.·ulrur.11 (cm1pch.·ni:c, -.od1! rc,pon,ihilJt) .• mJ ttlnb.il .JW.Jrcnc" In 1) ;I.I. Hillin~, & J. A, H,1,tcJd t h1' 1. Tt·11d1111.11 ,,, 1111rmtn: A..n/1/tlr .f•ir Ji1rnlt_vi 5tlt cJ .. Pl'· l11'.'"-209 ,. \t I oui,, :110· fJ-..,,i,r

~Jtmn1I [...:Jgu.: fi1r ~ur~in~. t 1972 !. Cnuri11 for 1/Jt npp1·ni11TI of l111rrnl1111rartt nntl IJ{('lu,· tl(ITl"l.'f prn ... m·nm,"' ,uu-sutn· ~C\\ York. S\': ~..1t1rnul L:.1.ftUC ti ir Sur-..in~ Pr.:~,

~.uiunJI L.:.11,tuc tt1r :-,,;u,,mp, t l'177' Cnl(rua f,,r r/J, (1•nfontr,m of td1unrium,I JwogrnmJ i11 11ur111(tf '"'''"' .. " tr, t'fll ,us,,r111tt dr...11,.a 15th c .. l.). ~c,\ Y,,rk. !\:Y ~.,ri,111.)I I.c,l!?,Llt: for :..._:ursu1~ rrc'\~.

518 Unit IV Application of Theory in Nursing

~t.:\\ nlJ.n, l) ~l I 100H ( ont.:i:ptuJ.J mnLkl, of nur"mg_ J.nd hai:- L·a.l.mrc.m.: nur.i.mc; cJuc.umn. Jn11r11al o{ X1n:01111 fd11cnt1011. .r, ~I. l'N-200. • . •

Uh. , .. De (;J~nc. r. c., & J..:.m~. I I 201 JI .-\ rnic\\ 11f tc,1.:h- 111~ lc.un111~ ,trJ.h:g.1t.·, to lx-: U\Ct.l ,,uh him for prclh.:cm,urc ,tulknr,. f,iun111I o( Su,·smJr P,iutnn,m. ;2i ,1 •· 150-150.

C.Y~ciL C. (20l:i1. Tc:.u.-hin~ m onhm.· k.irning cn,1runmcnh. In ~I H. \krm.mn I F.d. 1. 7i·nrlm,.n i11 111mi1tn n11d ml,· ~f rhr al1unt,11·: n,,. tomplttt' ._1111idt It• btst p,·nrtiu in uni/11·11_,,. n•n/11- ,rtw11 n1uf o,rrrru!11m dn·d11pmo1t !pp. l0.~-l l6 L ~c\\ York. ~\': Spring<r Puhlishmit.

l',Jdcn DcnmcJd. M. 1.., \c,ilid,. R ,\I., Kak,. R. ;I.I.. & F.m,<lc. :\ L t.201(,1. "iimuk1t1011 wuh d1.:l'tncti11~ .ind ~uidcJ rc.:-tkal,c 1otm1.1l1ng. to ,tunul.ltt: ,rtt11.:J( t lunk111g: m prd1\.'.cn,tlrl' hJi.:-(.1 1.wn:Jn..· d.:~rl'l! mar~mµ. "itud..:nr,. /ounurl t') ,\·urru~n l:dut"dtJt111, ·'-" 11 ,. M~- c,50 ""i· JO 3'128 / 0l~S-H\H-20)c,)UI 1-Oi

P.,~c C'111r,1r.1. K .. & Turlr.. ;I.I 1201 71 Jmp,Kc of prcbricfing 011 ..:t,mJH.'tcnc..-y pcrformJ11..:c. dim,,: .11 judgment .111d c:\pcriL'JKC m .;u11ul.1tic111: A.11 c,pc.:rurn;nr.11 (otlh.h . • \'11rs,· l:.d11cntum Tdlfa.,. -1111 I 1, 78- 8.~. drn:IO.IOl<>/1.nc,lt.2016.09.012

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Philhps, , t-.1 12016 ) StrJh.·g.1t.'"- to prnmott: .;rudcnt c.:11~.1gcnH.·nr .md .1.:ci,c k.1rni11!' 111 n. ,\I. llillin!'' & I .-\. H,btcJd I Eck,. ·fr,uhi11f1 i11 lllffJWJ1.' A Jlllltfr _fiw_(nn,Jr..,, ( ~rh ed .. pp. :?-l-;\-262 1

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