Authors

1. Wilson, Rosemary
2. Godfrey, Christina M
3. Sears, Kim
4. Medves, Jennifer
5. Ross-White, Amanda
6. Lambert, Natalie

Abstract

Review question/objective: The objective of this review is to examine conceptual and/or theoretical frameworks that are relevant to nurse practitioner education.

The specific review question is: What conceptual and/or theoretical frameworks are available that are relevant to the structuring of nurse practitioner education?

Background: The use of conceptual and theoretical frameworks to organize the educational curriculum of nursing programs is essential to protect and preserve the focus and clarity of nursing's distinct contribution to health care.1 Conceptual frameworks of nursing provide a means to look at nursing in relationship to external factors, thereby assigning meaning to the practice.1 Graduate level nursing education in the preparation of Nurse Practitioners (NPs) specifically and Advanced Practice Nurses (APNs) in general, is significantly compromised by the tendency to conceptualize the learning in these complex programs as being primarily related to skills-based tasks and competencies alone. According to Baumann,2 advanced nursing education must focus on the uniqueness of the NP position, in contrast to other health care professions. To do this, Baumann2 suggests using a conceptual nursing model and nursing theory as opposed to a strictly biomedical model. This allows NPs to interpret information in a way that differs from the strict biomedical model, providing opportunities for the NPs to be truly present in the lives of their patients.

Canadian Nurse Practitioner (NP) practice competency documents are based primarily on the Canadian Nurses Association (CNA) Nurse Practitioner (NP) Core Competency Framework.3 This document defines the core set of entry-level competencies required for all NPs to practice in all Canadian jurisdictions, settings and client populations. The Core Competencies in the CNA NP Framework are organized within four main categories: professional role, responsibility and accountability; health assessment and diagnosis; therapeutic management; and health promotion and prevention of illness and injury. Although vital to the organization of provincial entry-level registration standards, this framework provides little direction to educational providers for curricula organization and philosophical perspectives.

The Canadian Association of Schools of Nursing developed a national framework for NP education4 following a multi-phase consultation and literature and curriculum synthesis project. While the task force addressed the guiding principles and essential components of NP education along with contextual factors that impact on the delivery of curricula in Canadian jurisdictions, the philosophical approaches guiding and organizing the education were not addressed.

A similar set of documents has been created in the United States by the National Organization of Nurse Practitioner Faculties (NONPF).5 These documents are organized by six population level foci (including the specialty of family/individual across the lifespan) and outline core competencies for entry to practice and registration and educational standards. The Core Competency documents provided by the NONPF are presented in the same manner as the CNA NP Framework and likewise, do not provide a guiding or organizing framework or philosophy for NP education.

A full curriculum overhaul based on the NONPF competency requirements was performed at a university center in Oregon.6 The new curriculum was based on competencies that students must acquire, rather than learning objectives.6 While the NONPF Framework does provide an extensive list of entry-level requirements for NPs, the challenges faced by the institution as it aimed to incorporate the framework into the curriculum clearly provide evidence that these overarching frameworks need to include both a philosophical and organizational component to help guide educators.

Conceptual frameworks in graduate nursing education

Conceptual frameworks are useful for establishing a congruent relationship between program curricula, objectives and content. Walker and Avant7 advance the utility of conceptual frameworks as providing the logic behind the interrelationships of terms and variables, and improving explanation and understanding. Gold, Haas & King1 assert that conceptual frameworks facilitate grounding of a nursing lens in the curricula of advanced practice nursing programs. It has been noted that newly practicing NPs have demonstrated an allegiance withmedical model thinking, second only in importance to wellness/health promotion considerations.8 Blasdell and colleagues9 surveyed 188 practicing NPs to investigate the relationship between education and the use of theory in clinical practice. Educated graduate NPs rated the importance of nursing theory to the NP practice role significantly higher than did diploma and baccalaureate degree NPs (4.05+/-2.06 versus 2.65+/-1.69, p<.001) but both groups rated the nursing models as less important for practice than a medical model approach.

Huckabay10 highlighted the need for the use of a harmonized nursing model at the undergraduate level to ensure that students have a thorough understanding of what nursing is and what nursing care entails. At the graduate level, Huckabay10 suggested the use of multiple nursing models, depending on specialty. Regardless of the educational level, a conceptual framework used for education must enable nurse educators to have sufficient guidelines to construct a curriculum and determine what knowledge and skills are needed by the nursing students.11 Further, Furlong12 identified the need for Advanced Practice Nursing (APN) curriculae to be innovative and critically reflective, preparing students to be readily adaptable to challenges in the work place. Furlong12 suggests that to do this, the curriculum must rely upon an interdisciplinary framework to deliver content. Gold, Haas & King1 suggest that core curricula based on a medical model or a skill-related task list do not reflect the critical thinking of nurses, nor the uniqueness of the profession. Thus, conceptual models used for curricula development must: encompass the distinct nursing worldview, promote learning, and be efficient and comprehensive.

Frameworks have been proposed and tested to guide the development and implementation of inter-professional education (IPE) and collaborative practice curricula for NP and medical students. A qualitative assessment of a framework guided IPE module illustrated the benefit of improving the focus on role awareness in participating students.10 However, this particular curriculum was limited to a two-week period and not presented as a pervasive approach to the educational programs of each discipline.

In education, an overarching philosophy can provide a road map for goal identification, teaching material development and the formulation of evaluation methods.1 For instance, when creating a curriculum that was a result of the collaboration of three different post-secondary institutions, the SHARE (students, humor, administrative support, resources, and educational technology) model was used.13 This model brings together resources, students and faculty, surrounding them with humor, which was viewed as a fundamental part of the process while the program was still in its early stages.13 According to the authors, the program has been widely successful and the reliance on humor as an underlying philosophy has enabled the students and faculty to deal with problems arising in the new program.13

Focusing on evaluation, Kapborg & Fischbein14 promoted the use of the Education Interaction Model. The model identifies how educational influences can interact with abilities of students and how the consequences of this interaction can be evaluated by observing changes in both students and programs. The authors argue that, while the educational interaction model is effective, it is not the only model that can be used to carry out evaluations.14 The authors stress that the model chosen to perform an evaluation should be based upon what or who is going to be evaluated.

The standards outlined in the CNA NP framework are an essential part of organizing the education process for NPs and ensuring that NPs have acquired the necessary skills to practice in Canada as an NP. However, the framework is lacking philosophy and organization regarding NP education programs to ensure that the curriculum is preparing the NPs for the ever-changing work environment.

An Australian survey of NP education documents from relevant universities as well as interviews with NPs and academic conveners from Australia and New Zealand found that, while NP educational programs need to have strong clinical and science based learning components, student directed and flexible learning models act to ensure the capability of NPs as they strive to adapt to practice situations.15 Capability, as an approach to the learning process, includes the flexibility to respond to the specific, self-identified learning needs of students.15 Knowing how to learn, having high self-efficacy, applying competencies to new tasks, collaborating with others, and being creative are all signs of a capable practitioner.16 Gardner et al.15 emphasized the need for a program that fosters both competent and capable NPs. In a follow-up study, using the same data, Gardner et al.17 confirmed that NPs viewed the attributes of a capable NP as imperative to practice. Thus, a framework for NP education must include both competency building elements, such as those currently found in the CNA NP framework and capability building elements which can be fostered through self-directed learning.17

Similarly, Schaefer18 investigated the role of caring in nursing practice through a class for APN students in which the students reflected on their narratives of caring for patients. This qualitative study revealed that when APN students provide care by meeting the complex needs of suffering patients, the art and science of nursing combine.18 The emphasis on care as a pervading part of nursing practice ensures that patients receive high quality care and maintain a sense of dignity, even with poor health outcomes. A curriculum based solely on competencies fails to incorporate not only the capabilities that are important for a successful practice, but also the caring nature of nurses that must be developed. Thus, a conceptual framework that includes competencies, philosophy and organization is essential to advanced nursing curriculum formation.

Purpose

An assessment of available conceptual and/or theoretical frameworks for graduate education in nursing generally, and for nurse practitioner education specifically, is required with the ultimate goal of providing recommendations for adaptation or adoption as a unifying approach. As such, the review will aim to answer the following questions:

What conceptual and/or theoretical frameworks are currently available in the literature for nurse practitioner education?

What frameworks are available for graduate level nursing education in general?

How can the identified frameworks be adapted or adopted for use in current education practices?

A preliminary search of Cochrane Database of Systematic Reviews, Joanna Briggs Institute Library of systematic reviews, Medline, CINAHL, PSYCINFO and PROSPERO has been done and no systematic or scoping reviews were located on this topic.