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Chapter 1. Introduction 1 Chapter 1 Introduction 1.1 Introduction Healthcare is changing dramatically due to the advancement of medical sciences and technology, the abundance of clinical research and the higher demands of consumers. As a key profession of healthcare, these changes represent a significant challenge to the nursing profession and nursing education in terms of maintaining the quality of services and preparing nurses for the future (MacLeod & Farrell 1994; Aiken, Sloane & Sochalski 1998; International Council of Nurses 1999; Long 2004; Bartels 2005; Covaleski 2005; Candela, Dalley & Benzel-Lindley 2006). Effective systems for regulation, education, research and management are key to strengthening the contribution of nursing services in order to achieve the required improvement in health outcomes (WHO 2002a). In response, nursing education is increasingly being restructured in many countries to prepare nurses for contemporary and future demands of healthcare (Spitzer 1998; Alderman 2001; Booth 2002). Many countries around the world have realised the importance of higher education for nurses, and most countries are moving in this direction. The World Health Organisation Global Advisory Group in 1992 recommended that, when appropriate, countries should move basic nursing education to university standards (Modly, Zanotti, Poletti & Fitzpatrick 1995). This view was supported by many countries around the world, moving from hospital-based apprenticeship training to university- based education, enabling the acquisition of bachelor degree education as a minimum preparation for beginning professional nursing practice (Royal College of Nursing 1997; Pearson & Peels 2001b; Zabalegui, Macia, Marquez, Ricoma, Nuin, Mariscal, Pedraz, German & Moncho 2006; AACN 2007; CNA 2007). It is evident that bachelor of nursing (baccalaureate-nursing) graduates acquire unique skills as clinicians and demonstrate an important role in the delivery of safe patient care (Goode, Pinkerton, McCausland, Southard, Graham & Krsek 2001; McKinley, Chapter 1. Introduction 2 Aitken, Doig & Liu 2001; Aiken, Clarke, Cheung, Sloane & Silber 2003; AACN 2005, 2007). In Sri Lanka, pre-registration nursing education is currently based on a three-year certificate level nursing program in schools of nursing that are attached to the Ministry of Health and four-year bachelor programs in nursing at universities. The government policy is that nursing education should be based on the four-year undergraduate nursing program (Ministry of Health 1992; Ministry of Health Nutrition and Welfare 2002; University Grant Commission 2007). In response, the University Grant Commission of Sri Lanka has approved four-year Bachelor of Science in Nursing programs (BScN) in three universities (University Grant Commission 2007). In addition to the proposed affiliation of existing schools of nursing to the university sector, several other universities including the Open University proposed to establish similar programs in the future (de Silva 2004; Dharmaratne, Goonasekara & Fernando 2006). However, there is no evidence to support the contention that existing and proposed undergraduate nursing curricula in universities are based on a common philosophy or an acceptable needs assessment. A lack of separate nursing council and national nursing competency standards are major challenges to develop a national level framework for nursing education in Sri Lanka. Although Sri Lanka has achieved a relatively high health status given its low level of spending on healthcare services, a large segment of the population still experiences vital health problems at all stages of life, mainly due to lifestyle and the demographic changes accompanying the epidemiological transition (Jayasekara 2001; Jayasekara & Schultz 2007). Thus, it is essential that nursing curricula reflect the existing and future needs of healthcare in Sri Lanka, while focusing on rapidly changing technology and healthcare interventions. However, there is no research that has focused on nursing education in Sri Lanka. Some reported studies have been conducted in small-scale evaluative formats within a single school of nursing and focused only on a limited number of program outcomes (Ministry of Health Nutrition & Welfare 2002). In this context of nursing education, the development of a conceptual framework that uses evidence to underpin undergraduate nursing curricula is a crucially important step to improving nursing education and nursing practice in Sri Lanka. Chapter 1. Introduction 3 1.2 Purpose of the study The overall purpose of this study was to develop an evidence-based conceptual framework for undergraduate nursing curricula in Sri Lanka. 1.3 Aims This study sets out to: Identify the nature and role of conceptual frameworks shaping nursing curricula; Synthesise the evidence on effectiveness, appropriateness and feasibility of current curricula models/conceptual frameworks, and their potential applicability in Sri Lanka; Analyse current trends and issues in global, regional (South-East Asia) and local (Sri Lanka) healthcare, and nursing education; Develop a conceptual framework using the above findings and views and opinions of key stakeholders of nursing education in Sri Lanka. 1.4 The process The process of developing the conceptual framework involved several steps: 1. Analysing nursing and educational theories and concepts to understand the nature of conceptual frameworks within nursing curricula; 2. Conducting comprehensive systematic reviews to establish: (i) the effectiveness and appropriateness of undergraduate nursing curricula, and (ii) the feasibility and appropriateness of introducing the nursing curricula from developed countries into developing countries; 3. Analysing current trends and issues in global, regional and Sri Lankan healthcare, and nursing education to capture the concepts that should be addressed in the conceptual framework; 4. Developing a draft conceptual framework using the above findings; 5. Evaluating the feasibility and appropriateness of the draft conceptual framework in Sri Lanka, getting feedback and opinions from the key stakeholders of nursing profession; 6. Developing an evidence-based conceptual framework that is feasible and meaningful in Sri Lankan context. Chapter 1. Introduction 4 1.5 Definitions 1.5.1 Conceptual framework in nursing curricula The term ‘conceptual framework’ is synonymous with the terms conceptual model, conceptual system, paradigm, theoretical framework, curriculum theory/themes (Bevis 1989; Sohn 1991; Fawcett 1995; Chinn & Kramer 1999). Boland (1998 p.135) defines the role of a conceptual framework in a nursing curricula in providing “faculty with a means of conceptualising and organising the knowledge, skills, values, and beliefs critical to the delivery of a coherent curriculum that facilitates the achievement of the desired curriculum outcomes”. 1.5.2 Undergraduate nursing curricula The term ‘undergraduate’ is synonymous with the terms bachelor or baccalaureate. The present study defines undergraduate nursing curricula as the formal plan of study that provides the philosophical underpinnings, goals, and guidelines for the delivery of pre-registration nursing programs at universities (Quinn 1994; Keating 2006). 1.6 Theoretical framework The process of developing a conceptual framework used an evidence-based approach derived from the Joanna Briggs Institute’s (JBI) model of evidence-based healthcare (Pearson, Wiechula & Lockwood 2005). The term evidence is used in this process to mean the basis of belief; the substantiation or confirmation that is needed in order to decide a claim or view should be trusted (Pearson 2004; Pearson, Wiechula & Lockwood 2005). This evidence-based approach generated knowledge and evidence to effectively and appropriately meet the needs of developing a conceptual framework in ways that are feasible and meaningful to a Sri Lankan context. The theoretical and conceptual underpinning of the meanings of the terms feasibility (extent to which an activity is physically, culturally or financially practical or possible within a given context), appropriateness (the extent to which an activity fits with or is apt in a situation) , meaningfulness (relates to the personal experience, opinions, values, thoughts, beliefs, and interpretations of patients or clients) and effectiveness (the extent to which an intervention, when used appropriately, achieves the intended effect) were as the theoretical framework of the study (Pearson et al. 2005). Chapter 1. Introduction 5 In addition, the JBI method of systematic reviews was used to synthesise the evidence on effectiveness, appropriateness and feasibility of current curricula models/ conceptual frameworks, and its potential applicability in Sri Lanka. Focus groups were used to seek feedback on the draft conceptual framework from key stakeholders in Sri Lanka. Focus groups are the most appropriate method to generate meaningful opinions, suggestions and feedback (Krueger & Casey 2000; McLafferty 2004). In fact, focus groups have clear potential where the researcher is interested in processes whereby a group jointly constructs meaning about a topic. 1.7 Summary of the thesis Chapter 2: Literature reviews The second chapter presents four detailed literature reviews. The topics were: 1. Conceptual frameworks in nursing curricula: This section examines the theoretical assumption of the conceptual framework for nursing and nursing education. 2. Global and regional trends and issues in nursing services
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