Moving Forward in Nursing Education Using the Backward Design

Background of Nursing Education

According to Benner (2012), a nursing theorist, a radical transformation needs to take place in nursing education; specifically, Benner believes in the need to provide a system where creativity and innovation are given due space to flourish amid educational processes. To do so, educators need to integrate classroom teaching with clinical practice in order to be able to prepare students to meet the future demands and challenges of healthcare. In 1982, Benner (1982) developed the concept of going “from novice to expert” in nursing, which was instrumental for stakeholders to directly and clearly grasp the various steps that nurses must achieve in order to reach expertise. Of importance, the knowledge extent in the study allowed numerous subsequent educational stakeholders in better preparing new nurses for the challenges of the real, clinical setting (Handwerker, 2012).

Considering these remarks on the need for a transformation in nursing education, educators now have the challenge of developing new and effective curricula, preferably ones that emphasize understanding and sensitivity toward vulnerable patients from various cultures. Thus, these curricular changes should focus on promoting cultural competency in learners, which can be operationalized by procedures that promote the acquisition of knowledge, attitude, and skills on the topic. Specifically, graduates tend to acquire cultural competency through carefully planned didactic content. These courses are developed to build a framework for learning. Generally, nursing education courses that focus on cultural competency present concepts for students based on a specific didactical approach, and the hope is that students can translate their learning into actions in clinical settings, as in homeless shelters, foster care, domestic violence shelters, which may thereby support sensitive care amid diversity and the promotion of role model competency in nursing care (Calvillo et al., 2009).

Currently, to be able to accurately examine education program effectiveness, different nursing education systems are developing evaluation plans that include formative and summative assessments. According to Benner (2012), the traditional methods of teaching in nursing have changed, in that clinical experience must now be integrated into nursing education contents. Confirming this, educators have recently found that lectures, drills, and content memorization do not encourage/challenge learners to engage in and develop critical thinking (Billings, 2005). Moreover, when nursing students take multiple-choice exams, they are obligated to pick one correct response, a process that is now understood as being a potential barrier to critical thinking (Oermann et al., 2000). Furthermore, as nurse educators move toward a more student-centered approach, content overload interferes with the development of critical thinking (Ironside, 2005).

Since complexities and patient volumes have been arising in healthcare systems, nursing students nearing graduation need to have had the opportunity to learn how to prioritize nursing care processes in order to be capable of solving real clinical problems when they appear. This requires emphasis on educational initiatives that promote critical thinking for dealing with changes in patient status (Tanner, 2006). In nursing practice and research, critical thinking is believed to play a significant role in the utilization of BWD. The BWD may provide a framework to strengthen and improve curricular implementation in order to meet the challenges of today’s healthcare by creating opportunities for nurse educators to focus on learner-centered outcomes and prioritize content in order to create meaningful learning and critical thinking for nursing students.

Furthermore, the reality of nurses is that their clinical practice puts them in the center of dilemmas that demand effective, and often quick, solutions. A question that deserves to be answered is: What should nursing students know, understand and apply to the clinical setting? The BWD begins with the development of a clear conception of the desired outcomes. The focus becomes for the nurse educator to recognize the desired outcome or competencies the nursing student must implement in the clinical setting and design a curriculum that initiates a development of deep and enduring understanding. Research shows that, although some daily clinical problems are easy to solve, the complex ones require multiple solutions, implying that nurses dealing with such challenges must be skillful in finding safe alternative (Oermann et al., 2000; Schultz, 2009; Shreeve, 2008; Stassen et al., 2011). Entry to nursing practice is guided by the desired program outcomes provided by resources available in the Essentials of Baccalaureate Education for Professional Nursing Practice (2018) and the National Council State Boards of Nursing Licensure Examination (2012) (National Council of State Boards of Nursing, 2012). These organizations provide the framework for identifying concepts and processes expected for the generalist nurse. Therefore, the BWD, can assist the nurse educator to determine how the curricular should be designed in order to demonstrate competency and efficiency as these student nurses utilize their critical thinking in the clinical practice setting.

Consequently, nurse educators must explore alternative techniques that promote critical thinking in students (Schuster, 2000; Vacek, 2009; Yildirim & Ozkahraman, 2011). Innovative teaching strategies (e.g., such as case studies, mind mapping, concept mapping, problem-based learning, and cooperative learning) have been shown to promote learner engagement and move away from engaging them in rote memorization practices (Ironside, 2005). In this context comes BWD, which is an inclusive model that integrates various modes of learning (e.g., inquiry- and project-based learning), as well as provides a relevant framework for developing a step-by-step approach that promotes the skills and knowledge that students need to develop an in-depth understanding of complex materials. It also shifts the focus from “rote memorization” educational initiatives to those that promote critical thinking. The BWD provides the development for assessment strategies in order to determine the desired outcome or the competencies for informed teaching and learning strategies. The BWD serves to strengthen the curriculum by prioritizing content and focusing on learner-centered outcomes thereby creating meaningful learning and understanding for clinical practice (Emory, 2014).

In essence, when nursing students are challenged to work in solving clinical real-life problems, their clinical experience becomes their classroom. Now, when using the BWD in a project-based learning initiative, teachers may request students to work in groups (e.g., by engaging in simulation scenarios) to try and solve these challenging clinical problems. This enables learners to simulate decision-making on how to approach a clinical problem and which decision to pursue. Thus, the use of project-based learning and BWD may enable students to gather information from various sources, synthesize and analyze the information, and derive knowledge from the learning experience. This shows how BWD enables nurse educator to reflect upon what they want the students to learn before constructing the syllabus. Moreover, research shows that the use of inquiry-based learning promotes ongoing assessments of learning outcomes, which further enhances the process of learning through questioning, engaging, and synthesizing authentic knowledge (Ratzer & Jaeger, 2014). The BWD models serves to initiate this process when designing the curriculum.

Content Overload in Nursing Education

Owing to the advancements in technology and the increase in accessibility and the amount of web-based information, nursing faculty now strive to teach clinical practice topics using only the best available evidence. To obtain the best possible evidence, educators should generally engage in rigorous search endeavors in the Internet for the newest information and use technology to gain access to research evidence of the highest quality. Moreover, the guidelines of evidence-based practice require practitioners to extract the best possible practical pathways based on evidence from well-designed studies, namely, studies rooted in scientific and clinical expertise. Indeed, studies that yield high-level findings tend to lead to improved quality of care, patient outcomes, and decreased healthcare costs (Melnyk et al., 2012, p. 410).

Generally, published nursing and medical research can be found by both the general public and health professionals on relevant academic search engines, including PubMed, MEDLINE, OVID, and CINAHL. Faculty members are among the largest users of evidence-based guidelines and recent research, and they often collaborate with other professional organizations to develop and implement clinical practice education courses for students. In using these media for accessing and delivering information (i.e., the Internet, educational technology, and social media), faculty members provide a strong foundation for nursing education. Moreover, the use of all these media by faculty members may promote the integration of new information into the changing nursing curricula.

Meanwhile, although faculty who are teacher-centered may have a sense that they must cover all the content necessary to promote students with educational growth, nursing faculty are often forced to address changing paradigms in nursing practice. Here, the BWD serves to address the ongoing paradigm shifts in nursing academia by focusing on learning goals, not on teaching processes.

Nursing Education: The Status Quo

According to Benner (2012), current practical nursing entails thoughtful, intentional, and purposeful application of nursing knowledge, denoting that nursing education must be correspondingly prepared to set these foundations, which will ensure safe nursing care in the near future. On this topic, the construct of intentional learning is relevant, which refers to the “persistent, continual process of acquiring, understanding, and using a variety of strategies to improve one’s ability to attain and apply knowledge” (Francis et al., 1995). Therefore, the BWD serves as the foundation for the development of learning courses. Empirical findings have reported that nurse educators are not teaching to promote conducive learning, which is a type of learning that should provide an environment devoid of physical intimidation and emotional frustration, namely, that allows for a free exchange of ideas (Ziwira, 2015). Moreover, for students to use their knowledge, they must understand how it can be applied and its relation to the “bigger picture,” namely, both from a learning and an application standpoint (White, 1997). As Hannah (2006) described, “nursing education content is challenging, and educators must strive to incorporate innovative strategies that encourage students to think critically and apply nursing concepts in a variety of patient situations” (p.239). Therefore, the BWD serves as a model to provide assessment strategies in order to determine achievement of desired outcomes or competencies which informs the educator whether teaching and learning strategies have taken place. This is accomplished through the six different facets of knowledge transfer (Figure 1). These facets provide evidence for outcome achievements and competency measurement. For example, understanding is demonstrated by the student’s ability to explain, interpret, apply, perceive, empathize, and self-evaluate (Wiggins & McTighe, 2005).OPEN IN VIEWER

According to the American Association of Colleges of Nursing (AACN) (2020), owing to the shortage of nurse educators, budget constraints, aging educators, and increasing job competition from the clinical sites, nursing programs in the United States of America are limiting their student capacity. The consequence of this situation is the hiring of nursing faculty who have clinical/research experiences but lack the pedagogical preparation for teaching nursing in a classroom (American Association of Colleges of Nursing, 2020), which leads to the continued growth for professional nursing educators in academia. Moreover, when there is a limited number of nursing professionals to perform critical services, patient safety concerns and the likelihood of the delivery of harmful nursing care may rise. Therefore, the need for nurse educators to accomplish and meet the challenges of duly preparing students for performing optimally and efficiently in clinical settings is an imperative issue (AACN, 2020). Nonetheless, the reality is that nurse faculty, often comprised of professionals with clinical experience, however, they may be lacking pedagogical knowledge, which leads to academic struggles and may lead to difficulty in deciphering the content which is important and relevant for students’ comprehension. This leads to content saturation and content repetition within and between nursing courses (Krisman-Scott et al., 1998). Therefore, the BWD may assist the nurse educator in developing assessment evidence by examining students’ responses in exams and performances. Well-developed methods of assessment may ensure that learning comprehension has taken place.

Summary

BWD model serves as a framework upon which the nurse educator develops an educational plan which will focus on learning outcomes, standards, and assessments. In doing so, the assessments will guide the development of learning activities, which are positioned to serve as a scaffold toward learning goals; which will then enable the students to learn the content. The more facets in the BWD model that are being used to demonstrate or explain a concept, the more likely the student will begin to understand the content. However, in the BWD not all facets may be evident for student understanding, therefore, the educator needs to decide which teaching strategies will be more effective in order to clarify or emphasize learning activities (Emory, 2014).

Regarding learning, Sousa (2011) affirmed that there are “no teaching methods that are best for all students all of the time” (p. 101). Owing to this understanding it is necessary to keep students actively involved in learning; successful teachers must use various teaching strategies, as the teaching method of choice depends on learners’ information retention ability. Considering this, it may just be that strengthening students’ understanding of and connection to knowledge and practice remains as a major challenge faced by educators. Encouraging critical thinking in nursing involves promoting problem-focused thinking, which naturally leads to the prioritization of patient care. Moreover, in nursing, critical thinking is supposed to assess the outcome measures of quality care, safety, and competency, which are all related to evidence-based practice guidelines. Generally, these skills are observed in students when they have acquired a broader base of knowledge and are able to integrate new knowledge in the classroom with their prior knowledge from the clinical setting. Therefore, content-driven lecture presentations often result in students engaging in rote memorization because of the lack of self-learning activities (Tanner, 2006). According to the Wiggins and McTighe, “teaching on its’ own never causes learning; only successful attempts by the learner to actively participate to learn causes learning. Achievement is the result of the learner successfully making sense of the teaching” (p.228). BWD is the model that guides the underpinnings of this reflection paper. In BWD, the process begins with the development and a clear focus on the concept that will lead to the desired outcome, and enable students to work backward in order to draw upon on content that was learned to reach the desired outcome. Hence, BWD serves to assist educators in creating lessons that focus on learning goals, not teaching processes.