Curriculum development: curriculum design

Designing a curriculum supportive of advanced practice nursing along with providing core elements of the level of education required for role preparation is imperative in programme planning. The initial Programme Manager was responsible for developing the curriculum with the format for curriculum design informed by visits overseas to countries with a history of APN development and implementation. In addition, consultancies from experts with knowledge of graduate nursing education plus a review of APN and nurse practitioner literature facilitated curriculum development. Most visits, consultancy expertise and cited literature utilised for curriculum design were based on knowledge or documents originating from the USA. The curriculum was created and developed at a time when the programme was under the jurisdiction of the School of Medicine contributing to a level of uncertainty as to whom or what should guide the curriculum. The question as to who had control over curriculum development is expressed in this quote by Head of Department of Nursing:

‘There were some challenges with the development of the … curriculum and as Head of Department it was essential that I work on several issues simultaneously related to ownership of the curriculum. The Director, Division of Graduate Medical Studies was not inclined to pass the programme to the Department of Nursing even though the department had been established in 2006’ [Participant 13NEd].

The establishment of the APN programme prior to the presence of a nursing department in the university led to misunderstandings and disagreement as to the focus for the course. There was ambiguity as to the basis and core principles that should be emphasised in the curriculum. Findings revealed differing viewpoints on the question of whether the APN role should be based on a medical model or a nursing model. A nursing leader who provided early direction for the APN initiative provided a perspective on the aim of the curriculum with this quote:

‘A medical model was followed for the curriculum with lectures by doctors and later senior nurses. [It is a] medical model in terms of curriculum but the role is nursing. The first batch of APN masters students was considered to be the cream of clinical nurses but nursing leaders felt they had deserted nursing. Directors of Nursing saw the role as medicine not nursing. When the Master of Nursing graduates returned to practice the Directors of Nursing wanted them to remain in the old role. They

[nurses] go to the Master of Nursing programme and they [Directors of Nursing] still want them to do the same thing.’ [Participant 4NL]

The debate surrounding a medical focus versus a nursing focus for the APN role and associated education emerged consistently throughout the findings and contributed to uncertainty in programme development, planning the clinical internship period and organising the qualifying processes for licensure. Therefore, even though enthusiasm evolved for the APN concept there was no evidence of a clear idea or consensus on what a nurse in this capacity should do. Further discussion of issues related to lack of role clarity and role ambiguity can be found in Chapter 8 on role implementation. The initial curriculum design (based on an18 month timeline) was largely theory based with clinical attachments undertaken overseas but only as observation of clinical practice thus lacking hands on experience. There were no role models in place in Singapore so there was no opportunity for the students to gain first hand clinical practice experience with APNs. Following completion of the education programme and during a clinical internship period clinical skills of assessment and clinical management were developed with clinical tutors. By the time data collection ceased in 2011 there had been some evolution to provide clinical experience in Singapore during the course but there were still limited role models. Although graduates of the programme were required to progress on to a clinical internship in order to qualify for APN licensure there was no established connection between the university programme and their subsequent internship placement. A description of the

internship period and internship experiences can be found in a later section of this chapter. In addition to the initial course, in 2007/2008 in response to demand from the medical

community a curriculum was developed for a separate cohort of critical care APN students. The critical care curriculum was introduced for ten students independent of the mainstream cohorts of APN students and was under the direction of the nursing department. This was a one off cohort based on the original curriculum design but developed separately for the critical care specialty and designed for a 24-month educational period. Development for the critical care cohort occurred as championed by one Director of Nursing and one influential cardiologist. One institution in Singapore had the vision and funding to influence this change. Curriculum development for the critical care cohort influenced future revisions for the entire APN programme. A revision of the initial curriculum occurred in 2008 and followed the design of the critical care curriculum. Changes were integrated into the entire programme and it moved from an 18 month to a 24-month timeline to establish closer alignment with the university as well as international standards for APN education. Some new modules were added and some were eliminated. The rationale for revisions follows:

 Modules viewed as not relevant to the programme were removed (E.g. critical thinking taught in the English department re ecosystems);

 18 months was viewed as too tightly scheduled for the students;  Additional theoretical clinical modules were added;

 The curriculum was benchmarked against international standards, especially from those countries with well developed 24-month curricula for the masters prepared APN.

Once the revision for the 24-month curriculum was accepted core modules were

established. At the time of completion of data collection new optional modules, e.g. primary care and palliative care had been added and new specialty streams, e.g. paediatrics, were being considered. An unclear APN role definition continued to provide challenges for development of the curriculum. Issues related to the direction and emphasis for the curriculum arose as key decision makers changed. Participants depicted uncertainty as to whom or what entity should have ultimate and continued authority over programme and curriculum development. One academic participant portrayed a perspective of the wide-ranging authority associated with the Ministry of Health and the Singapore Nursing Board with the following quote:

‘I think that the Ministry of Health has a great role in the development of the education, particularly the Singapore Nursing Board, because even though the university is sort of independent … they [Singapore Nursing Board] will have a lot to say about what modules, how many clinical hours, things like that. I would think the influence of the people in the government and the healthcare sector and the ministry is actually very important in moulding the modules … or subjects being taught’ (Participant 6NEd)

When participants were asked ‘do you think university officials are aware of the standards and regulations that the Ministry of Health and Singapore Nursing Board have provided for APNs?’ the same academic participant responded with the following quote:

‘I think that the university people wouldn’t actually know the details. Maybe they have a broad view but the nitty gritty details I do not think they actually know. We submit documents and the Head of Department … approves them. People in the university think … the Head of Department should know and has approved it but the whole purpose of the documents … they [university decision makers] actually cannot be bothered with because they know they have trusted this person [Head of Department, nursing] who actually has dealings with the Ministry of Health or the Singapore Nursing Board people’ [Participant 6NEd]

Most participants concurred with this perspective but were unsure about what people on the ground actually knew. The Singapore Nursing Board had a lot of influence over education for nursing but participants associated with the university nursing department implied that the university as a separate entity should have more influence over the APN programme. Findings revealed varied levels of trust in decision makers at governmental and regulatory levels to have sufficient knowledge and ability to make informed decisions influencing the educational process for APNs. Academic participants suggested that if key decision makers did not have expertise in educational preparation for APN roles they would not have been able to determine the flaws in the processes of curriculum design and programme

development. In addition, concern emerged about the extensive control of the Singapore Nursing Board over programme development in terms of curriculum development and programme accreditation. In summary, this subsection has demonstrated the complexities of curriculum development for APN preparation. In the beginning phases of curriculum design changes of personnel in positions of authority, differing opinions on the focus for the APN course and discontinuity in the operational model contributed to uncertainty. At the completion of data collection in 2011 revisions to the curriculum continued in response to feedback and comments from nursing, medical representatives and students. The next subsection describes the challenges in identifying and obtaining qualified teaching faculty and staff for the APN programme.