Restructured nursing curricula are needed to address the challenge of content overload and increasing knowledge and skills required to practice nursing.1-3 Pedagogies of integration are necessary to transform nursing education from a linear, content-driven approach to one that fosters synthesis and context.1 The process of integrative learning has been defined as developing student abilities to make, recognize, and evaluate connections across disparate concepts or context.4 There can be a disconnect between individual courses, even within a defined program of study.5 The ability to "pull it all together" enables students to apply concepts and constructs across contexts and fosters lifelong learning.5-7 This is particularly important in nursing education, given the complexity of today's health care environment. This article describes a curricular innovation incorporating a series of stand-alone integrative seminar courses, developed and implemented by the authors, to facilitate integrative learning across the baccalaureate nursing programs at 2 northeastern US universities.

Curricular Structure

Both schools of nursing implemented a series of required weekly stand-alone integrative seminar courses across their baccalaureate programs. These courses began with the first clinical course in both universities (Table 1, Supplemental Digital Content, http://links.lww.com/NE/A440). Class size was capped at 15 in university 1 and students self-selected into sections. At university 2, students were directly enrolled into sections capped at 24 students, corresponding with assigned clinicals to facilitate discussion of common experiences. University 1 has primarily traditional baccalaureate students with an average cohort size of 250. University 2 has mostly second-degree students with approximately 220 students per cohort.

Seminar Design

Seminar courses at both universities were intentionally designed as stand-alone courses with learning outcomes that complemented concurrent nursing course content. As courses increased in complexity, students engaged in progressively higher-level integrative thinking and clinical decision making in the seminars.

The seminars implemented a scaffolding approach that built on previous knowledge and focused on student-centered learning using unfolding case studies, high-fidelity simulations, narrative reflection assignments, and other team-based learning activities.8 Students were provided with the opportunity to synthesize and apply knowledge in context using realistic patient scenarios, problem solve situations from multiple points of view, and make connections between theory and clinical practice.1 All learning activities were designed to help students make connections across and between concurrent courses (Supplemental Digital Content 2, http://links.lww.com/NE/A441).

Teaching Strategies

Unfolding Case Studies

Consistent unfolding case studies across course sections were used in each university based on student feedback and faculty preference. Published or faculty-developed cases were distributed to students in advance to enhance discussion during the seminar. Cases had structured debriefing guidelines and incorporated professional, ethical, quality and safety, interprofessional collaboration, and communication competencies.9-11 University 2 also implemented student presentations of actual clinical cases. Students were encouraged to ask questions and problem solve collectively to develop a patient plan of care.

High-Fidelity Simulation

High-fidelity simulations eventually replaced the published case studies at University 1. Simulations fostered integrative thinking by students, supporting them to make connections and apply concepts across concurrent courses. Simulation debriefing is essential to help students integrate concepts and reflect on their learning.12

Narrative Reflection Assignments

Guided reflection and narrative pedagogy have been shown to promote clinical decision making and integrative thinking in nursing students as well as seasoned nurses.3,10 University 1 students composed narrative reflection papers based on sequential themes addressed each semester: (1) safety, (2) communication, (3) interprofessional collaboration, and (4) prioritization/delegation. The other school incorporated reflection guidelines based on the Tanner clinical judgment model.6 These strategies emphasized the value of reflection, challenged students to put learning in context, and guided professional role development.1,5,6 Students were required to examine their clinical practice from the view of what went well, what did not go well, and what would I do differently.

Root-Cause Analysis

Root-cause analysis for a sentinel event based on a patient case scenario has been identified as an effective way to teach students about patient safety and just culture.13 In University 1, patient case scenarios facilitated problem identification and use of quality improvement tools, for example, cause and effect analysis using fishbone diagrams. Students engaged in role play in a realistic sentinel event scenario to better understand health care team member roles and functions and to see the vital connection between effective health care team member communication and patient safety.11

Student Feedback and Lessons Learned

Student feedback was collected via end-of-semester course evaluations. Overall, students enjoyed the seminars and described their professional growth and integrative learning through faculty and peer interactions. Class discussions were often spirited exchanges where students examined alternate viewpoints, addressed ethical dilemmas, analyzed challenges to professional practice, and constructed strategies collaboratively to address complex issues.

Students described the integrative seminars as helping them in making connections between their didactic classes and clinical experiences in a safe environment that was conducive to learning how to apply clinical skills, discuss practice issues, and address professional challenges. They talked about narrowing the theory to practice gap by using "tools to help with [clinical] challenges." Many expressed feeling more comfortable in clinical and learning what the real world is like and how the system actually works. Students expressed the seminars enhanced their professional development, making them better future nurses. They recognized the need to be patient-centered advocates and communicated the importance of delivering quality care.

The benefits of student-centered learning approaches are well supported in the literature.8 However, they require a different set of instructional skills and expertise than traditional, teacher-centered classroom methods.1 Faculty development was an important consideration at both universities. Students reported greater satisfaction with the seminars overall when they perceived the faculty facilitator to be knowledgeable of the clinical subject matter, organized, engaging, and student centered. Faculty and classroom space shortages, inconsistency in course delivery, and various teaching approaches presented challenges in both universities. As a result, university 1 changed the seminars to 100 minutes every other week and replaced unfolding cases with high-fidelity simulation. Despite their success, university 2 discontinued the integrative seminars after 3 years because of limited faculty resources, large student enrollments, and lack of small classroom space following relocation to a new building.

Summary

Implementing pedagogical approaches to facilitate student learning is an important goal in nursing education. Student integrative thinking and the ability to connect knowledge and skills across the baccalaureate nursing curriculum are essential to successful transition to professional practice. Incorporating a series of stand-alone integrative seminar courses may facilitate development of these higher-level skills. These courses provide dedicated opportunities to connect theory to practice, contextualize learning, and enhance professional role development. With appropriate resources and administrative support, this innovative curricular approach can assist prelicensure nursing students to develop habits of mind that foster integrative thinking and promote clinical decision making.

References